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MPS Symposium on Substance Abuse

Author: Bruce Hershfield, MD
Publication Year: Spring 2007
Edition Summer 2007; Vol. 33, No. 3; Pg 3, 13
Type of resource: Newsletter


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.


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