By Bruce Hershfield, MD
[Summer 2007; Vol. 33, No. 3; Pg 3, 13]
One
hundred ten people attended the MPS symposium on “Substance Abuse: Diagnosis
& Treatment in 2007–-Questions for the Experts”, held at the Hunt Valley
Marriott on March 31st.
The faculty, which included MPS members Scott Aaronson, Eric Strain, and
Christopher Welsh, presented a well-organized, unbiased look at what we know
about this important subject.
After
Dr. Aaronson introduced the day’s program, Dr. Welsh, who has been practicing
at the University of Maryland since 1997, told us about “changing patterns and
changing drugs”.
Prescription opiates have overtaken marijuana as the leading type of
illicit drug use, he pointed out, and patients may not even know what they are
using.
GHB, a CNS depressant also known as “liquid X” that is used by models
and body builders, has replaced Rohypnol as the “date rape” drug.
As examples of new or revived forms of substance abuse, he cited
nebulized alcohol, the use of ethanol-based hand sanitizers, and the drinking of
absinthe.
Some people have been “snorting” Wellbutrin, getting an
amphetamine-like effect that can cause seizures. He also mentioned high-dose
caffeine, dextromethorphan, and morning glory seeds as representing substances
that are abused.
For
his second presentation, Dr. Welsh talked about dual diagnosis–“Addiction
& Mood & Psychotic Disorders”.
He began by pointing out that 72% of drug abusers have at least one other
psychiatric disorder.
One-half of people who suffer from schizophrenia have a substance abuse
disorder, as do 56% of those who have bipolar disorder and 18% of those who have
a major depression.
He added that 23% of those with ADHD and 60-80% of those with antisocial
personality disorder also have a substance abuse problem.
“Which causes which?” Or, “Are they related in some unknown way”
are issues that he explored.
The treatments have developed independently, he pointed out, and they
often are delivered in parallel, instead of sequentially or as part of an
integrated system.
Since
suicide is three to four times more common in substance abusers (and it may be
30 times more common in people with alcohol dependence) than in the general
population, Dr. Welsh made it clear that dual diagnosis issues are important for
psychiatrists.
After
a mid-morning break, Betsy F. Amey, LCSW-C, a Past-President of the Maryland
Society for Clinical Social Work, talked about special populations–-“Is
Addiction Treatment Different for Certain Individuals?”
The treatment variables she listed included co-occurring disorders, age,
gender, family support, and socio-economic factors–-along with “readiness to
change”.
She told us that family therapy works best for young adolescents and that
cognitive behavioral therapy with “consultations” from friends works well
with older ones.
She went on to describe the problems that geriatric patients have with
alcohol and analgesics.
She then listed the different levels of care, including short-term and
long-term addiction rehab, halfway houses, therapeutic communities, and
detoxification, before finishing with a summary of the role of dialectical
behavioral therapy.
After
a panel discussion and then lunch, Eric Strain, MD, who is a Professor at Johns
Hopkins, lectured about the medications available to treat addiction.
Among the new ones, he singled out tramadol (Ultram), which is the only
non-scheduled opioid agonist and also is an SNRI, rimonabant(Acomplia), which is
a cannabinoid receptor antagonist that might decrease appetite, and
methynaltrexone, which may be useful for constipation secondary to opioid use
because it is not absorbed when taken orally.
He also described new formulations of existing medications, including
depot, transdermal, and implantable buproprion.
“What needs to be done?” he asked.
He sees a need for safer treatments, for example those that are unlikely
to cause liver damage.
Finally, he emphasized the role of non-pharmacologic treatments.
In
the last of the lectures, Mr. Richard Prodey, who works at Sheppard-Pratt and
also at Loyola High School, spoke about “Predicting Relapse & Recovery”.
He began by describing which features predict successful treatment,
including attending AA/NA meetings, severing connections with drug-using
acquaintances, and accepting aftercare recommendations even when they are
difficult.
Signs of impending relapse include persistent resentment, isolation of
affect when patients tell their stories, and anxiety/sleep disturbance in the
post-acute withdrawal phase.
Patients who are at great risk for relapse complain about going to AA/NA
meetings, return to environments that are not helpful, and have long histories
of severe symptoms and of prior relapses.
He concluded by telling us about “therapeutic relapses”, which are of
short duration, cause minimal consequences, and lead to learning.
A
panel discussion--“How Do We Integrate Care?”--concluded an interesting and
useful program.
