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WORKSHOP SESSIONS
Networked National Initiatives Workshop I: Encoding Practice into Research: The Strategies and Implementation of Networked National Initiatives Richard Rawson, PhD; University of California-Los Angeles, Los Angeles, CA; William F. Haning III, MD, University of Hawaii, Honolulu, HI; and Scott Sutherland, DO, University of Hawaii, Honolulu, HI The use of methamphetamine is a major public health and criminal justice problem in some parts of the United States and in many parts of the world. Treatments for methamphetamine dependence have limited empirical support. Currently, there are no pharmacotherapies with demonstrated efficacy for the treatment of methamphetamine use disorders. At the present time there have been fewer than 10 controlled, double-blind trials of potential agents for the treatment of methamphetamine-related disorders. The National Institute on Drug Abuse (NIDA) has made the development of medications for this purpose a priority. Among the biggest obstacles in meeting this challenge is the establishment of clinical research sites in geographic areas of the United States where methamphetamine use is prevalent enough to allow for the recruitment of a sufficient number of methamphetamine users into clinical trials. The NIDA Methamphetamine Clinical Trials Group (MCTG) is a new initiative by NIDA to create a network of clinical research sites capable of conducting high quality clinical trials to assess potentially useful medications for the treatment of methamphetamine-related disorders. In the initial effort, five sites and a coordinating center have been selected by NIDA. The sites are in Costa Mesa and San Diego, California; Des Moines, Iowa; Kansas City, Missouri; and Honolulu, Hawaii. The coordinating center is in Los Angeles at UCLA. The actual integration of medication trials and clinical treatment in the outpatient setting, having been set as a priority of NIDA, required a set of acquired skills and organizational templates. This workshop offered a short course in design and implementation of such projects and outlined their future with the federal research institutes. Those who have an interest in participating in these multi-center efforts as a means to developing institutional research vigor learned about the pros and cons of involvement and the expected way marks in developing a research/practice grid. The cases employed in instruction included one behavioral and two medicinal clinical trials in the management of methamphetamine dependence. A particular focus was the cross-cultural issues that arose in establishing geographically disparate multi-center trials, and the approaches that were developed to deal with them.
Hawaii’s involvement process began in December 1999. An organizing meeting was held in April 2001 and was followed by a NIDA site visit on May 1. Numerous conference calls and submission of the design followed. The target date for kick-off and training was September 1, 2001. Site development steps included the following:
The following training issues encountered were:
The project then experienced an unexpected interruption of its intentions: the pharmaceutical vendor produced an impediment. The original trial was designed with bupropion sustained release (150 mg.) in mind, and we found that only the brand-name vendor provides the SR form. The brand-name vendor balked at the 11th hour. The following response strategies were considered:
In collaboration with NIDA and the UCLA team, the project began preparation of alternate medication treatment trials. Simultaneously, non-medication trials were initiated to establish a foundation for assessing medication trials and to preserve the research network. The study objectives became:
By October 2001, Hawaii became the last site to clear IRB hurdles and begin recruitment. The development of a medication clinical trial with ondansetron began with a target date of February-March 2002. References: Srisuranapanont M, et al. Amphetamine withdrawal: I. Reliability, validity and factor structure of a measure. Aust NZ J Psych. 1999;33:89-93.
Workshop II: Physician Health and Addiction Sponsored by the Betty Ford Center Anne Linton, MD, Betty Ford Center, Rancho Mirage, CA; Peter A. Mansky, MD, New York State Physician Health Program, Slingerlands, NY; and Penelope P. Ziegler, MD, The William J. Farley Center, Williamsburg, VA Dr. Linton reported on a case of a 49-year-old, separated MD who had a history of four previous treatments for chemical dependency. Based on a recent report to the medical board of impairment at work, the physician health program sent patient for multidisciplinary residential evaluation. The patient’s mother had died; he was separated and dealing with a malpractice suit. His physical stressors included a past injury with neck pain worsening over the past year (his MRI revealed C6-C7 disc herniation), and he had been working 90+ hours a week. He had been treated for depression since age 14 with multiple medical trials and was currently on Wellbutrin SR 150mg BID but not compliant. His chemical dependency dated back to 1984. In 1987 he was in long-term residential treatment program for health professionals. In 1994, he was in inpatient treatment for one month and then involved with the Physician Health Program and monitoring for 5 years. His drug/alcohol use over the past year included: MSContin, Dilaudid, Demerol and Oxycodone, Xanax, and Valium. He had been drinking intermittently since 1994 but with increased frequency and had experienced a blackout recently. The assessment recommendations included:
His treatment included: detoxification with clonidine, phenobarbital, and prn Robaxin and Neurontin for pain and post acute withdrawal. He was continued on Effexor XR. The treatment included: biofeedback for pain and anxiety after detoxification process, participation in a cognitive therapy group for depression/chronic pain, and group therapy for addictive disease as well as 12-Step involvement. The patient completed 13 weeks of residential/day treatment and was drug/alcohol free, was not depressed, and had minimal neck pain. He returned to participation in the State Physician Health Program for Monitoring/Aftercare. Dr. Mansky presented an overview of physician health programs. The AMA urged states to address the issue of impaired physicians in 1974. From this charge grew such programs as Physicians Helping Physicians and Peer Assistance Programs. Illnesses addressed included substance abuse disorders and other psychiatric illnesses, e.g., Axis I and Axis II types, neurological diseases such as dementia, head injury, and stress. The FSPHP Directory shows the following illnesses addressed:
Physician health programs functional elements include: outreach and education, case identification and referral, intervention, clinical evaluation, monitoring, and advocacy. The outreach and education effort focuses on at-risk specialties. The top five specialties at risk are internal medicine (18%), anesthesia (11%), family practice (11%), psychiatry (10%), and OB/GYN (7.65%). The least common specialties at risk are pathology (1.39%), plastic surgery (1.22%), neurosurgery (1.04%), and thoracic surgery (0.35%). In the category of relative risk, we find the highest risk for emergency medicine (3.14%), anesthesia (3.04%), and plastic surgery (1.81%). The drugs of choice are alcohol (55%), opioids (25%), cocaine (10%), sedatives (4%), stimulants (3%), marijuana (2%), and hallucinogens (1%). After participating in the physician health programs, we find no relapse for 88.48%, one relapse for 8.03%, two relapses for 3.14%, and three relapses for 0.35%. Medical professionals suffering from SUD are both the same and different than other addicts. However, in planning treatment the general differences in the physician population must be taken into consideration. These include the experience with pharmacological optimism (seen medicines treat patients, working well, and treat quickly); intellectual strength (ability to solve problems); strong willed; love of challenges (feel they can conquer the appetitive nature of chemical dependency); and a daily need for denial. As physicians we see normal denial all the time. Medical caregivers often learn to deny aspects of disease and death.State laws now mandate reporting professional misconduct; habitual use of drugs or alcohol is considered misconduct. Practicing medicine while impaired by alcohol, drugs, physical disability, or mental disability is considered misconduct. Physicians can expect some degree of confidentiality while in treatment except when there is imminent danger to public health, the patient is non-compliant with Committee for Physician Health (CPH) program, or the impairment is not alleviated by treatment. Dr. Ziegler presented a sample pain management protocol for a patient, "John Jones." The patient presented with a pain management issue derived from migraine headaches. A team approach for the treatment protocol included a Daily Maintenance Program with:
The patient was assigned to specific groups and appointments were made with different staff as follows:
In response to a headache, the patient was instructed to:
The patient was assigned the task of creating a Headache Recovery Diary; it was designed to:
The pharmacologic interventions are tailored to meet the needs of each patient. The protocol includes use of the FACES Pain Rating Scale. The pain management process group is a weekly-facilitated small group experience designed to encourage patients to express feelings about living with chronic pain. It also addresses grief. The first three steps of the 12-Step program are explored as they relate to chronic or recurrent illness. The pain management process group becomes a support group within the therapeutic community for patients learning to live without opioid and/or sedative drugs for pain.
Workshop III: International Practices and Perspectives in Addiction Psychiatry Nady el-Guebaly, MD and David N. Crockford, MD, RCPC, University of Calgary and the Addiction Centre, Foothills Hospital, Calgary, Canada; and Alvaro Zomosa Matthews, MD, Unidad de Orientacion y Psicodiagnostico, Guadalajara, Mexico Goal: The International Members Workshop is designed to provide an opportunity for international members of the AAAP to present their original research as well as pertinent reviews on addiction psychiatry topics. Ultimately, it is hoped that by providing a forum for worldwide experiences and perspectives on addiction psychiatry for the membership at large, that the overall knowledge base for best treatment practices of addictions patients will be enhanced. The inaugural workshop occurred this year with the following three separate presentations. An International Perspective on Addiction Psychiatry – Dr. el-Guebaly: Based on international collegiality created by the World Psychiatric Association and the International Society of Addiction Medicine, involvement with the American Academy of Addiction Psychiatry, as well as visits to more than 30 countries worldwide, Dr. el-Guebaly presented a personal perspective on the challenges facing addiction psychiatry. Specific topics of discussion included the following:
Zuclopenthixol in the Agitated Cocaine Abuser – Dr. Zomosa Matthews: In Mexico, the use of cocaine has rapidly increased over the last five years relating to increased financial means, decreased street drug costs, and expanding access. Now cocaine represents the most common illicit drug of abuse in Mexico, second only to marijuana. In particular, the prevalence of cocaine use disorders in Guadalajara, home to Dr. Matthews, has skyrocketed. Cocaine-addicted patients are notoriously difficult to treat based on their impulsivity, agitation, and early flight from treatment. The need for additional treatment strategies for this patient population gave rise to a preliminary trial involving Zuclopenthixol acetate (an antipsychotic used in Europe, Canada, and Latin America whose effect lasts approximately 48-72 hours). Sixty-nine individuals meeting DSM-IV criteria for cocaine abuse/dependence were selected. Ages were between 18 and 38 years with average daily use of two grams per day. Each subject received 50mg Zuclopenthixol acetate IM with this repeated in eight hours in cases of severe agitation or psychosis. Overall, Zuclopenthixol acetate demonstrated good tolerability with less extrapyramidal side effects than prior experience with other antipsychotics (although direct comparison was not made). Good sedation and relaxation was provided which ultimately facilitated faster integration into addiction treatment/rehabilitation. It was concluded that Zuclopenthixol acetate may thus represent an additional pharmacologic choice in the management of the agitated cocaine abuser.
Marijuana and Psychiatry – Dr. Crockford: Marijuana use historically has been viewed in a dichotomous fashion with public policy on its use ebbing and flowing based upon political motivations of the time rather than scientific realities. Currently, Canadian federal policy is diverging from federal policy in the United States with access on compassionate grounds being advocated (with the exception of five U.S. states). While the cannabinoids have the potential for therapeutic use, little scientific evidence is present to justify current government initiatives. Smoked marijuana remains a problematic delivery mechanism for the cannabinoids due to adverse smoking related effects (especially with low potency source), dosing problems, issues of dependence, and significant deleterious effects on cognition and psychomotor performance. The future of an inhaler may mitigate some adverse effects but currently is not a viable treatment option. Used acutely and for terminal states it has limited but credible scientific support whereas the treatment of chronic disorders especially those of a psychiatric nature have no current supporting evidence. Marijuana use is associated with the development of toxic deliriums, exacerbation of psychoses, and indirectly associated with an increased prevalence of anxiety and depressive disorders. However, there remains no robust evidence that marijuana causes chronic mental illness. Pain syndrome management with the cannabinoids has a supportive basis in neurobiology, but clinical trial support for the role in management of chronic pain is lacking. Canada health policy needs to be altered so that "medicinal" marijuana users are involved in rigorous clinical investigations to allow a definitive statement to be made on the place of marijuana, if any, in medical practice. Also, practitioners need to be aware that the prescription of marijuana or a permissive stance on its use carries with it significant legal liability. In general, there appears to be no support for the use of marijuana or the cannabinoids in the management of any psychiatric disorder and, in fact, use likely would cause more harm than it would be expected to remedy.
Workshop IV: Treating Attention Deficit/Hyperactivity Disorder Among Families Suffering from Addictions Jeffrey J. Wilson, MD, and Frances R. Levin, MD, Columbia University and New York State Psychiatric Institute; Estelle Paris, MD, Columbia University, New York State Psychiatric Institute, New York, NY, contributed to this workshop. She was unable to attend the Annual Meeting.
Attention deficit/hyperactivity disorder (ADHD) is a common childhood disorder that often continues to manifest symptoms into adulthood. In children and adults, this condition may contribute to addictive vulnerability. Several factors are common to the developmental psychopathology of these conditions, suggesting an underlying deficit in behavioral regulation as an explanation for this comorbidity. Developmentally faulty learning processes or attempts to self-medicate dysfunctional behavior may contribute to the pathogenesis of substance use disorders (SUD). Substance abuse itself may also contribute to the development of attentional deficits and behavioral dysregulation through direct (e.g. prenatal or self-inflicted) exposures to neurotoxic substances and indirect (e.g., poverty, neglect, abuse, etc.) mechanisms. Since ADHD can be identified prior to the peak onset of substance use, effective treatment of this common disorder may reduce the development of substance use disorders. Adult ADHD may also contribute to the development and maintenance of substance use disorders. Substance abusers with ADHD may particularly benefit from treatment of this comorbidity. However, the treatment of ADHD among families suffering from addiction is complicated by several factors including: ongoing substance abuse by a family member, potential diversion within or without the family, familial concerns about promoting drug abuse, treatment program concerns about promoting drug abuse, possible interactions with drug abuse, etc. Early age of onset for SUD is associated with childhood onset of antisocial behaviors—low harm avoidance, low reward dependency, and high novelty seeking activities. For example, with disruptive behavior disorders, ADHD youth are two times at risk for SUD. Patients with CD (Conduct Disorder) + ADHD are four times at risk for SUD. In children with ODD (Oppositional Defiant Disorder) we find about 30% develop CD and about 30% develop ASPD (antisocial personality disorder). The usual age of onset of ADHD is pre-K, i.e., symptoms before age seven, but this criterion is not easy to determine for adults and some adolescents. An essential element of the diagnosis is behavioral impairment in multiple settings (for children, this is usually at school and home), and this behavior cannot be better accounted for by another developmental or mental disorder (e.g. PTSD, depression). It is important to identify these problems as early as possible during development. ADHD symptoms produce functional impairments that often have cascading developmental impact in multiple areas: social, academic, emotional, and behavioral. Hence, early identification and treatment may reduce serious developmental problems. Treatment studies reviewed were evidence-based behavioral and pharmacologic; 99% of all research is on Caucasian boys. There are new advanced delivery systems (e.g., OROS™, biphasic pulse systems) that may reduce potential for abuse, but randomized clinical trials of these medications (buproprion, once-daily stimulants, tricyclics, Clonidine) among individuals with SUD are lacking. There is a relative paucity of behavioral therapy and combined medication/behavioral studies. The question of whether stimulants should be used in a substance-abusing patient was raised. As there are no simple answers, we need to carefully weigh the risks and the benefits of using these medications. The following considerations may be helpful in estimating the risk:benefit ratio:
In summary, among clinical samples of adolescent substance abusers, ADHD is a common problem that may interfere with treatment. In treating ADHD with SUDs during adolescence and adulthood, there may be a special role for behavioral therapy and family therapy, but medication treatments should not be absolutely contraindicated. Careful consideration of the individual patient’s risk:benefit ratio and family/treatment support is recommended. Combined interdisciplinary approaches are perhaps best suited to provide the necessary information for assessment as well as treatment. References:
Workshop V: Protracted Withdrawal States David Cohn, MD, Alta Bates Medical Center, Berkeley, CA
Is PWS (protracted withdrawal states) clinically obvious to practitioners? Several members of the AAAP wrote that PWS should be in the DSM-V. PWS is caused by a profusion of confusion. We psychiatrists are the lawyers of medicine. We choose and say things based on definitions and words, and we use symptom and syndrome descriptions rather than anatomical parts to define illness. Qualia is used as an operant term to define a sense of "being," while the Diagnostic and Statistical Manual of mental disorders is our taxonomy bible. Qualia is both phyisophysical and psychological. PWS is defined as a set of signs and symptoms that persist, evolve, or appear beyond an expected timeframe of AWS (alcohol withdrawal syndome); these signs and symptoms may fluctuate, remain the same, and/or come in waves. Over time these signs and symptoms usually diminish in quantity and quality. The Protracted Withdrawal Syndrome includes:
The workshop discussion addressed the effects of:
In examining nicotine and AWS where a patient has had daily use of nicotine for several weeks, the cessation or reduction of nicotine was followed within 24 hours by four of the following:
In PWS, the nicotine cessation results in
Psychiatrist Frank Miller in Treatment Addictions Journal presented two cases of protracted delirium. Protracted delirium is organic. In the protracted state there is a period where 55% of people feel bad. We know PWS follows AWS but don’t know exactly when it starts. A videotape was shown of a woman on Xanax for 10 years with involuntary movements; it took 11 days to stop the movements. Less acute withdrawal symptoms can last for weeks or months; chronic symptoms include anxiety, dysphoria, anhedonia, insomnia, and craving. With a pscyhostimulant there is evidence of an increased incidence of panic disorders and other anxiety disorders that occur in withdrawal. Long term symptoms of anxiety seen include:
The short term symptoms include:
The question is whether there is a pre-existing psychiatric diagnosis before drug abuse that complicates PWS can there be another psychiatric condition that is pre-existing? Studies haven’t been scientific enough to prove that there is something called PWS, although, clinically we know it exists. There needs to be more studies using a re-challenge method to help determine PWS. We know that with nicotine/AWS protracted withdrawal most acute symptoms go away in four weeks; however, hunger, weight gain, and craving can exist up to two years. Acknowledgement of the existence of the syndromes and then defining them in such a way as to be of clinical usefulness is needed. New methodologies and studies in basic neuroscience are needed for inclusion in the DSM-V. A work-study committee is needed to develop new diagnostic language.
Workshop VI: Gender Differences in Substance Abuse Treatment—Towards a Gender-Oriented Approach Patricia Isbell Ordorica, MD, Raul F. Nodal, MD, and Jamie R. Smolen, MD, Tampa VA Medical Center, University of South Florida College of Medicine, Tampa, FL Dr. Nodal described the need for gender specific treatment in certain subtypes of women. For example, gender-specific treatment is of the utmost importance for women in lower socioeconomic classes, i.e., those with poor parenting and social skills and those who have been in an abusive environment cycle. We need to teach them to make a living. Some gender-specific treatment for women offers social support and child day care. In examining the treatment-relevant subtypes of female substance abusers, the pregnant, IV-drug users and adolescent polydrug abusers receive the most attention in the literature and in federally-funded behavioral treatment research, while the subtype middle-class women are hard to identify in the research, i.e. single professionals, housewives, and seniors. Contingency management has been found to be effective in cocaine and opiate-dependent patients. There has been success with giving a three-day supply of methadone if there has been a negative toxicology screen so they don't have to visit each day. However, no gender differences have been found in literature reviews on contingency management. Coercion and drug treatment for postpartum women through court-mandated programs have been effective. If required to attend either a gender-specific intensive program or a traditional outpatient treatment program, women who were given custody of their children stayed in treatment longer; those in the intensive program had an even higher completion rate. In a randomized study, Dahlgren and Willander (1989) showed better outcomes for female alcohol abusers in women-only treatment programs than those in mixed-gender program. Copeland et al (1993) found women-only programs attracted some women who were demographically different from those in mixed gender programs. Behavioral therapies that have been supported by efficacy data include: behavior change techniques, cognitive therapy, couples therapy, personal psychotherapy, and abuse prevention. In a multi-systems model (MSM) for treating perinatal cocaine addiction, two stages of gender-specific (GS) coed peer-led programs were provided: I (N=21) targeted GS needs while at II (N=27) MSM was added to promote family reintegration. The controls (N=66 for stage I and 75 for II) were non-perinatal clients whose treatment remained the same during the corresponding periods. The study found that UDS (urine drug screen) and retention rates were significantly improved for Group II compared to I. In another study of 4,117 women in publicly-funded treatment in Los Angeles County, it was found that while women in women-only programs had more problems, they spent more time in treatment and were two times as likely to complete it compared to those in mixed-gender programs. There are success stories on gender-sensitive treatment. In one, the initial three-month inpatient treatment was followed by 21 months of continued comprehensive care with the result that 63% of the women were sober and living in the area after four years. In another study of extended care (259 days) of alcohol and substance abusing women who received support for childcare, educational/occupational training, and their victimization and psychological distress, it was found that 88% were substance-free at discharge and 49% had jobs or were enrolled in school/job training. Gender-specific therapeutic consider-ations indicate that buprenorphine may be a better choice for females. In Schottenfeld et al (1998), the study compared the effects of buprenorphine (4 or 12 mg sl) and methadone maintenance (20 or 65 mg) on opioids, benzodiazepines, and alcohol use in 80 male and 36 female patients randomly selected. There were no differences in ETOH/benzos use; rates for opioid abstinence were significantly higher for females in the 4mg buprenorphine group. Buprenorphine may be a safer alternative to methadone in pregnant patients. Children of mothers treated with methadone have low birth-weight: 2,748g vs. 2,925g for cocaine and 3,023g for controls. Studies to date have found normal birth weight in infants of mothers treated with buprenorphine and no or less incidence of Neonatal Abstinence Syndrome. In summary, there is a lack of gender-specific efficacy data; we need to evaluate the efficacy of interventions developed for females and the gender differences in efficacy of existing non-gender-specific treatments. Dr. Smolen described the effects of gender differences in alcohol metabolism. Alcohol related medical risks occur for both men and women. Men drink more than women do, and in larger quantities. They have more alcohol-related medical illnesses. Women, however, develop many medical-related problems at lower levels of consumption than men do; women develop alcohol dependence after fewer years of drinking than men. The pharmacology of alcohol consists of the following: it is a small molecule (not unlike water) that is not digested—hyperosmolar in the stomach; it is held in the stomach until isotonic-normal constrictions; it is rapidly absorbed from the small intestine; and it enters the system rapidly by simple diffusion. There is intrasubject variation: individuals who came in to be tested week after week had 8-10% variations with the same consumption. Alcohol metabolism has been more frequently studied in the last 10-15 years. Gender differences can be inconsistent. The duodenum readily absorbed gastric mucosa; there is faster gastric emptying in women. Women have less body H2O. In considering alcohol elimination rates we need to ask: Did the person have a meal with alcohol? Were they fasting? What was the meal size? What carbohydrates and proteins were in the meal? In measuring the rates of gastric emptying for women, the menstrual cycle plays a critical role. We must consider the luteal phase and pregnancy, high estradiol and progesterone levels, reduced GI motility, delayed gastric emptying, and variable alcohol delivery to intestine blood. Alcohol elimination rates differ based on genetic determinants; metabolic rates differ in genetic groups. In examining ADH2 Isoenzymes contribution to alcohol metabolism—in the Vmax-elimination rate Beta2 and Beta3 both have he same Vmax; Beta3 has a much lower Km than Beta2. When subjects are tested, it doesn't become active until people become intoxicated In examining the genetic determinates of ALDH, ALDH2*2 while a dominant inheritance becomes an inactive isoenzyme in Asians/Native Americans. This deficiency of ALDH2, results in their becoming flushed with modest amounts of alcohol. When comparing men and women in metabolic studies we find in alcohol dosing, by body-weight adjustment, that women have a smaller volume to distribute alcohol. When equivalent doses are given by weight, women will start higher on the blood alcohol concentration (BAC) time curve, and the BAC curve for men and women will not be comparable. Rapidity of absorption is important. The influence by sex hormones (pregnancy, pre and post menstrual) are not yet known. Women were identical in age at presentation of liver disease. Women progress to cirrhosis even after abstaining. Women with an alcohol intake of +60g a day became cirrhotic three times faster than men. When women reach a certain level of liver disease, they continue to progress even if they reduce or abstain from drinking while hepatic injury in men will not continue independently. Binge-drinking college students have gender neutral differences. In bars, women are gender-neutral in their drinking to keep up with men—five drinks for men and four drinks for women result in identical problems. This results in negative outcomes like risky sex and missing classes. There is a need for gender-specific definitions for bingeing and for college alcohol awareness programs. Questions to consider with intravenous cocaine use by women are: what is progesterone doing? Does estrogen lose its protective effect? Do men have a greater degree of vasoconstriction, higher rate of stroke? Are estrogen-like compounds shielding? A new study by Kauffman will examine when women get progesterone-greater vasoconstriction and when men get estrogen-less vasoconstriction. Intravenous cocaine in women was examined at two points—at the mid follicular phase and at the later luteal phase. MRI blood flow studies showed normal during follicular phase and had a 10% decrease in the luteal phase (vasoconstriction). Estrogen-like compounds shield the brain when cocaine injection occurs. With chronic cocaine abuse, higher rates of stroke and silent ischemia occur. Most brain damage is subtle, small electrical changes. When cocaine abuse continues during rehabilitation, estrogen could reduce brain dysfunction, and emotional deficits exist during recovery. The gender differences in response to cocaine include different craving through the monthly menstrual cycle for women, and the response to withdrawal may fluctuate with the cycle. Men had significantly more episodes of euphoria and dysphoria, greater heart rate and blood pressure increases, and men detected the effects of cocaine sooner. Dr. Ordorica presented information on the gender differences in substance abuse treatment and studies of psychiatric comorbidity. In studies of hospitalized alcoholics, women reported more depression, panic disorder, and phobia. They presented with more major depression and anxiety disorders; men presented with more Antisocial Personality Disorder. Female alcoholics have more psychiatric comorbidity than males. When examining drug-use disorders (other than alcohol and nicotine), there were subgroup gender differences. Women ages 45-54 had higher lifetime prevalence than men—3.8% of women to 2.1% men; this reflects higher prevalence of prescription drug dependence in women in this age group. Men have higher rates of dependence on illicit drugs. In examining depressive symptoms and drinking behavior, the post-addiction treatment relapse for women is primarily associated with depression. Initially in treatment, depression is found to promote change in motivated women and men. The treatment implications indicate that depressive symptoms post-treatment may be more indicative of relapse in women and untreated depressive symptoms may lead to poorer treatment outcomes in women. In one study of cocaine dependent men and women (n=298) women had almost two times more anxiety disorders. There were fairly equal rates of affective disorders—43% in men and 47% in women. Childhood ADHD and ASPD were slightly more common in men. Depressed individuals are more likely to smoke and are less successful in quit attempts. The link between depression and nicotine dependence appears to be stronger in women than men. Females using cocaine or opiates had the strongest predictors of PTSD. For women, a traumatic event is most likely to occur before the onset of substance dependence. In one study, women who reported a history of sexual assault had a life-time prevalence of alcohol abuse/dependence increase by three fold while life-time prevalence of drug abuse/dependence increased by four fold. In a study comparing women with alcoholism to a household sample, there were higher rates of childhood victimization in alcoholic women compared to nonalcoholic women when controlling for demographic and family background differences. In a longitudinal study of women in the United States, use of illicit drugs was strongly associated with both sexual and physical assault in women. The prominent risk factor for both alcohol and drug abuse/dependence in women is a history of physical and/or sexual abuse. There is evidence to suggest a genetic link between alcoholism in male relatives and major depressive disorder in women. It is essential to obtain a psychiatric history in all women with addictive disorders, with a special emphasis on temporal development of concurrent disorders. Women addicts with primary depression should be made aware of the possibility of recurrence; they can be educated to recognize early symptoms of a recurrent major depressive disorder. Vigorous treatment of depression is essential to avoid relapse and promote recovery. References:
Workshop VII: The Addiction Psychiatrist: Expanding the Consultant Role Stephen L. Dilts, MD, PhD, President, American Academy of Addiction Psychiatry and Jeanne G. Trumble-Hejduk, Executive Director, American Academy of Addiction Psychiatry
With greater frequency, the knowledge and skills of addiction specialists are in greater demand as generalist physicians and other health care providers are being increasingly called upon to deliver substance abuse prevention and treatment services. Research over the past several decades has consistently demonstrated that primary health care clinicians do not receive adequate training and preparation to address alcohol and drug abuse issues in their practice. With federal funding from the Center for Substance Abuse Prevention, the American Academy of Addiction Psychiatry developed training curricula for health care practitioners including primary care physicians. Comprehensive free-standing training manuals were developed, which have been used more than 80 times in the United States and in the newly independent states of the former Soviet Union. The goals and objectives of the training course are to:
Several key factors are important when working with primary care physicians:
After setting the stage about the extent of the problem and using the risk and resiliency framework that offers a context and rationale for providing both prevention and treatment services, practice information about intervening with patients is very important. An example of valuable information to transmit to primary care physicians can be found in the Screening Module of the curriculum. By the end of this module, it is expected that participants will be able to:
Although these objectives may seem very basic, most physicians have received little if any training in substance abuse issues and have a very low recognition rate of such problems in their practice. This, in spite of research that shows that a very large percentage of patients who come to a primary care physicians office are affected by a substance abuse problem—either their own or that of a family member. In addition to the skepticism related to viewing substance use disorders as legitimate medical conditions, there is often skepticism on the part of primary care physicians regarding the value of addiction psychiatrists’ roles. For this reason, it is often very helpful to identify a primary care physician with a special interest and expertise in substance abuse to jointly teach initial sessions. This will assist in establishing credibility and confidence. In addition, an interactive CD-ROM entitled: "We Can Make A Difference! The Physician’s Role in Substance Abuse Prevention" is available from the National Clearinghouse for Alcohol and Drug Information. This resource was developed as part of the American Academy of Addiction Psychiatry’s work with the Center for Substance Abuse Prevention. It demonstrates several office interviews that realistically portray a family physician’s office. Please contact the Academy for information on obtaining the curriculum materials upon which this presentation and the training courses are based. In addition to hard copy, plans to offer the course on the Web are also being explored with funding from the Substance Abuse and Mental Health Services Administration. It is very important for addiction psychiatrists to recognize and build upon the unique set of skills they have, especially in serving as a consultant to other medical specialists and other health care providers. In addition, many opportunities exist in the community to share your expertise: participate in screening days, give a talk at a local treatment program, or write or prepare testimony for local, state and national legislatures. All of these have also been found to be excellent practice builders!
Workshop VIII: Problematic Sexual Behavior and Substance Use Disorders Workshop Steven Brockway, MD, Chief Psychiatrist, The Meadows, Wickenburg, AZ; Richard Irons, MD, Professional Renewal Center, Lawrence, KS; and Peter R. Martin, MD, Professor of Psychiatry and Pharmacology, Director, Vanderbilt Addiction Center, Vanderbilt University Medical Center, Nashville, TN
Evaluation and treatment of substance- related disorders over the past two decades has demonstrated that a significant percentage of patients present with signs and symptoms of problematic sexual behavior. Furthermore, the role of sexual behavior as a trigger for relapse is well established. The purpose of this workshop was to explore the co-occurrence of problemmatic sexual behavior with substance disorders and the mechanistic understanding of this relationship. After the introduction by Dr. Martin, Drs. Brockway and Irons discussed in detail the distinct categories and variable expression of problematic hypersexuality which antedate the diagnosis of substance disorders and may persist, if not increase, during sustained remission. The discussion focused on current understanding of the possible mechanisms that may mediate the relationship between problematic sexual behavior and substance use disorders. These span the biopsychosocial domain and include common involvement of the reward pathways of the brain, common psychobiological mechanisms related to early trauma and/or attachment theory, among others. It was concluded that sexual symptoms, though very common in various psychiatric illnesses, have not received the attention they merit in nosology, diagnosis, and treatment. Clearly, further work in understanding problematic hypersexuality is in order and should serve to elucidate related psychiatric disorders, especially substance use disorders.
Workshop
IX: Diversion of
Prescription Drugs Abuse and diversion of prescription opioids and other controlled drugs has received increasing media attention recently. This workshop introduced several aspects of the topic. The presentations stimulated a great deal of audience participation, including a number of case vignettes highlighting the challenges of chronic pain management. Drs. Leo and Nahmias presented overviews of the topic. Diversion refers to the misappropriation of prescribed medications, either by physicians and/or individuals who acquire medications from treating sources. Prescription drug abuse accounts for almost 30% of the overall drug problem in the United States, representing a close challenge to cocaine addiction. For example, in 1998, about 2.4 billion prescriptions were written of which 254 million were for controlled substances. Although the amount diverted into illicit traffic is unknown, these drugs account for over 30% of all reported deaths and injuries. Legitimate drugs commonly found in the traffic are narcotics like hydromorphone, codeine, methadone, hydrocodone, and oxycodone. The issues around diversion have acquired increasing media, public, and legal attention related to the diversion of pain medications. Of late, concerns around diversion have focused on OxyContin. Initially, the appeal of the "Oxy Buzz" was epidemic in remote, rural areas. States in which OxyContin diversion had been problematic included Kentucky, Florida, Maine, and Maryland. However, its popularity has spread into larger cities and metropolises. Alarming Fact: since 1996, the number of OxyContin prescriptions dispensed increased 20-fold to approximately six million in 2000. Reports from 20 metropolitan areas indicated that oxycodone-related deaths and emergency department episodes have increased 400% and 100% respectively. Because of the high potential for abuse of narcotics, depressants, and stimulants, the Drug Enforcement Administration (DEA) and the Department of Health and Human Services put these substances under legal control through various treaties, the Controlled Substances Act, and other regulations. From a drug regulatory standpoint, however, diversion has been difficult to control because the medications are produced by legitimate pharmaceutical companies, prescribed by doctors, and dispensed (presumably) to legitimate patients. Further complicating the problem, the Internet has now become a major resource for acquiring prescription medications, including Oxycontin, with no direct physician contact. Typical diversion cases that are prosecuted include:
One recourse is to intensify restrictions and regulate the prescription of controlled medications. Naturally, concerns arise that legitimate (non-diverting) pain patients may be penalized because of these restrictions. The DEA is working with experts in pain management to devise strategies to make sure OxyContin is properly prescribed. Dr. Ziegler presented information about the diversion of opioids by health care professionals. By far, the majority of this diversion is for personal use by physicians, nurses, dentists, pharmacists, veterinarians, and other licensed professionals who are addicted to the drugs. Often the addictive disorder begins in the context of self-medication for a painful condition, with the professional harboring the erroneous and dangerous belief that knowledge of and experience with the medication will prevent the development of addiction. Hydrocodone is the most common pharmaceutical agent reported in these cases. Another pattern, seen especially in anesthesiologists, is experimentation provoked by curiosity about patients' intense euphoric responses to ultra-short-acting anesthetic opioids such as fentanyl. Professionals addicted to opioid have an excellent prognosis for recovery provided they receive adequate primary treatment followed by continuing care and monitoring. They should not return to immediate direct contact with opioid drugs following short-term primary treatment, but rather need to demonstrate their ability to maintain abstinence in an outpatient setting. Naltrexone can be a valuable adjunctive tool, but compliance must be monitored. Dr. Johnson described the psychodynamics and potential counter-transference issues involved in prescribing controlled substances to patients. The patient may present a tragic situation and insinuate that if the physician "really" cared, they would do something about it. The physician sympathizes with the patient's distress. The physician may be as unable as the patient to tolerate the helplessness involved. The physician derives a sense of power from the use of the drug, does not consciously identify the threat of abandonment if the drug is not supplied, and responds to the patient's hostile control by "disengaging" via issuing a prescription. As the situation deteriorates, the physician joins the patient in an alliance that idealizes the use of the drug, sees outsiders as uncaring and ignorant, and fights any consultation that suggests the use of addictive drugs has become a harmful endeavor.
Workshop X: Developments in Adolescent Substance Abuse Treatment Marc Fishman, MD, Mountain Manor Treatment Center, Baltimore, MD; and Geetha Subramaniam, MD, Johns Hopkins Hospital, Baltimore, MD Dr. Fishman discussed the role of the adolescent family network when considering treatment modalities. Comorbidity is the norm and the degree of severity is related to other problems. Reviewing the recovery patterns over 12 months, only a small number leave treatment better and stay better. A large number of patients come in "bad" and continue to have problems; and 29% have intermittent problems. CSAT has funded adolescent treatment models in 11 community treatment sites around country. They are (1) adolescent treatment models; (2) level of care groups; (3) therapeutic communities (TC) (long-term 12-15 months residential); and (4) short-term residential (STR) 30-90 days. There is a wide variety of different kinds of treatment in the different cities. There are several types of outpatient treatment with a variety of intensities: low intensity, residential, and step-down The Baltimore Short Term Residential (SRT) Mountain Manor Residential Treatment Program found marijuana to be the most prevalent drug of use followed by heroin and alcohol. The percent abstinent in the past 90 days was about 50% at three months, and at 25% for both six and nine months. There is abstinence and low frequency use for 90 days; and both abstinence and frequency decline from three months. There is approximately 45% abstinent and 70% frequency at three months; and approximately 26% abstinent and 44% frequency at nine months. With the baseline of substance use in the past 90 days of 83% using, it declines over time and at nine months less than 38% are using. There is still heavy involvement still at nine months in juvenile detention. In summary, the problem of adolescent substance abuse is severe and worsening according to many indicators; comorbid impairment is common. Treatment works but availability is very insufficient. Post-treatment reductions in use are related to substantial improvements. Dr. Subramaniam discussed the prevalence of psychiatric disorders in adolescents with substance use disorders (SUDs). In one community population study, it was found that psychiatric disorders preceded SUDs. [The prevalence rates included: conduct disorders (CD)~40-90%; mood disorders~16-55%; ADHD~8-33%; anxiety disorders~8-29%; and PTSD~3-18%.] The studies limitations included: difficulties with assessment and categorization; lack of agreement on diagnosis of SUDs; validity of diagnosis and assessment; differences in assessment; instruments and changing DSM criteria; and limited substance-specific data. The predictors of SUD (from a psychiatric perspective) include: CD—early onset; symptom severity; ADHD and CD—early onset SUD, persistence into adulthood; major depressive disorder (MDD), worse comorbidity; and other factors with MDD leading to SUD-CD, longer episodes, anxiety traits, and poor social support systems. Additionally, the hypothalmic-pituitary-axis needs consideration—peak age 15-19 years old. We find that in depression and SUD:
Workshop XI: Developing a Research Career: In Industry, Academia and the Public Sector Roger D. Weiss, MD, McLean Hospital, Belmont, MA; Edward V. Nunes, MD, Columbia University, New York State Psychiatric Institute, New York, NY; and Frances R. Levin, MD., Columbia University, New York State Psychiatric Institute, New York, NY
The focus of this workshop was the development of a research career. Dr. Nunes began the workshop by reviewing the process of developing a research proposal for NIH and submitting it for review. He reviewed the various types of grant applications available, including project grants and career development awards. He discussed the decision-making process regarding where and how a grant is reviewed, the process of review, scoring, percentiles, and funding decisions. He emphasized the separation between "program" people in the institutes such as NIDA and NIAAA vs. the review office. Dr. Weiss then discussed the criteria that are used to review federal grants, and he discussed the most common mistakes that junior investigators make when preparing proposals. These include overly ambitious plans, overly broad topic areas, and too little attention to demonstrating the feasibility of the project. The review criteria for the National Institute on Drug Abuse (NIDA) grants include the following: 1. SIGNIFICANCE
2. APPROACH
3. INNOVATION
4. INVESTIGATOR
5. ENVIRONMENT
Dr. Levin then spoke about career development awards and the process of choosing a mentor. A discussion then took place, including a discussion regarding ways in which people can conduct research without grants.
Workshop XII: Cultural Issues Related to HIV and Substance Use William B. Lawson, MD, PhD, FAPA, Howard University, Washington, DC
Transmission of AIDS/HIV is throughout the world. It is changing from men-to-men to men-to-women transmission, mother-to-child and women-to-women. Other permutations must be considered. The mother-to-child transmission occurs in 80% of the cases in African-Americans and Latinos. While AIDS/HIV is now controllable and preventable for spreading to the fetus, there is no reliable vaccine. African Americans and Latinos are at high risk; however, this has not been labeled a minority disease. Risk groups differ in African Americans; they clearly have more heterosexual transmission—drug addicted male to female and male with male to female. While the stigma of homosexuality is prevalent in this community, the sexual practices within the correctional system and the social practice of "down low" are avenues to further spread the disease. It is important in treatment to understand that men who have sex in jail or "down low" do not consider themselves gay. Both men and women believe the information about AIDS/HIV doesn’t apply to them. Access to services has had an impact on HIV-positive individual’s lifespan. Studies have shown that African-Americans have less access to a full range of services; family wealth is another contributing factor. Poverty limits access to treatment, especially the new techniques. Family resources may not be available when and where needed. Low rates of participation in clinical trials also is a factor. The psychological impact of AIDS can result in over-reaction. For example, church-going individuals deal with the stigma of suicide by the fatalism of believing that "God will take care of me." Young males (17-18 years old) don’t see the death and dying potential of the disease. The 14-year-olds ignore the facts. SSRIs are less available to African-Americans in general, females and the elderly. African-Americans are less likely to be treated by mental health professionals. Primary care clinics are not identifying the problems of HIV and depression. Tricyclic antidepressants are used in clinics in spite of the fact there are more side effects, have higher plasma levels, and higher plasma levels are found in completed suicides. It is difficult to get patients to take 20+ pills a day when they have the attitude "I’m going to die anyhow." Different delivery systems need to be developed like those for TB. Teaching doctors to try different approaches is an option. One approach is teaching cognitive behavior by telephoning the patient as a reminder. The approach worked well but was expensive. Dr. Lawson also discussed a recent trip to Senegal. Senegal is experienced in handling alcohol abuse but not cocaine. In the South African homelands, there are problems in disseminating information to countries with literacy rates of less than 50%; there are disproportionate resources, political issues, and high rates of rape—all affecting reduction in transmission. Prevention is key. The community needs AIDS education; it has to involve everyone, especially the faith community. Education through active informing and not passive slogans is critical. Prevention can work.
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