The Carlat Guide to Addiction Treatment: Ridiculously Practical Clinical Advice

By Michael Weaver

Substance use is very common among psychiatric patients. Depending on your practice, up to 50% of your patients suffer from an addiction that may be aggravating their primary symptoms. It is impractical to refer all such patients to addiction specialists, who are in short supply. This extremely practical guide will enhance your confidence in tre

• Language: English
• Publisher: Carlat Publishing, LLC
• Release date: Feb 3, 2017
• ISBN: 9780997510645

Michael Weaver

Michael Weaver is a historian of European politics and culture. His work has been supported by the German Academic Exchange Service (DAAD), the Joint Initiative in German and European Studies at the Munk School of Global Affairs & Public Policy, and the Anne Tanenbaum Centre for Jewish Studies at the University of Toronto. Michael holds a Ph.D. in history from the University of Toronto and is an independent scholar.

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Carlat Psychiatry

Addiction Treatment

Michael Weaver, MD, DFASAM

Professor of psychiatry at the University of Texas Health Science Center

in Houston, Texas

Medical director of the Center for Neurobehavioral Research on Addiction

Published by Carlat Publishing, LLC

PO Box 626, Newburyport, MA 01950

Copyright © 2017 All Rights Reserved.

Publisher and Editor-in-Chief: Daniel Carlat, MD

Executive Editor: Janice Jutras

All rights reserved. This book is protected by copyright.

This CME/CE activity is intended for psychiatrists, psychiatric nurses, psychologists, and other health care professionals with an interest in mental health. The Carlat CME Institute is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Carlat CME Institute is approved by the American Psychological Association to sponsor continuing education for psychologists. Carlat CME Institute maintains responsibility for this program and its content. The American Board of Psychiatry and Neurology has reviewed Addiction Treatment and has approved this program as a comprehensive Self-Assessment and CME Program, which is mandated by ABMS as a necessary component of maintenance of certification. Carlat CME Institute designates this enduring material educational activity for a maximum of four (4) ABPN Maintenance of Certification credits and eight (8) AMA PRA Category 1 Credits™ or 8 CEs for psychologists. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity. CME quizzes must be taken online at www.thecarlatreport.com or http://thecarlatcmeinstitute.com/self-assessment.

To order, visit www.thecarlatreport.com or call [phone]

ISBN #: 978-0-9975106-3-8

eISBN #: 978-0-9975106-4-5

1 2 3 4 5 6 7 8 9 10

Table of Contents

Introduction

Acknowledgments

Chapter 1:

How to Diagnose Substance Use Disorder

Chapter 2:

Drug Testing

Chapter 3:

Understanding Addiction Services

Chapter 4:

Psychotherapy

Chapter 5:

12-Step Programs

Chapter 6:

Dual Diagnosis

Chapter 7:

Alcohol

Chapter 8:

Sedatives

Chapter 9:

Nicotine

Chapter 10:

Cannabis

Chapter 11:

Opioids

Chapter 12:

Stimulants

Chapter 13:

Designer Drugs

Chapter 14:

Hallucinogens and Other Drugs

Appendix

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)

Clinical Opiate Withdrawal Scale

Drug Use Questionnaire (DAST-10)

Fagerström Test for Nicotine Dependence

Recommended Reading

References

Self-Test Answer Key

Introduction

I became interested in treating addictions as a medical student, and eventually, after doing a residency in internal medicine, completed a fellowship in addiction medicine. I found that in treating substance abuse, I could make a remarkable and rapid difference in people’s lives. Over the years, as we’ve developed new and more effective treatments, managing addiction is no longer the province of addiction specialists—nor should it be. General psychiatrists and primary care doctors can learn the basics of an effective approach to treatment, and can gain the immense satisfaction that comes with helping people make dramatic changes in their lives.

I’ve divided the book into two sections. In the first section, I teach you general skills applicable to any patient with a substance use problem. I share tips on efficiently screening for the use of different substances in the initial interview, as well as ascertaining the severity of the disorder. I teach you about the appropriate use of drug screens, including how to talk to your patients about problematic results. In addition, I give you some psychotherapy pointers that are especially applicable to a busy MD who may be able to budget no more than 20–30 minutes for patient follow-ups. I devote a whole chapter to 12-step programs because they are often misunderstood by both clinicians and patients. In the comorbidity chapter, I cover the common problem of patients who present with a non–substance use issue, but in whom you realize that an addiction may be contributing to the problem.

The second section is organized by specific substances of abuse. For each substance, I cover the essentials of what it is, how it works in the brain, and what sort of withdrawal symptoms are likely to occur. Then I discuss practical approaches to assessing the problem, followed by how to treat the patient. Treatments vary depending on the substance; sometimes they will be primarily psychosocial, other times mainly medication-based.

Finally, I’ve added various useful tools in the Appendix and have provided links to access these materials in the electronic version of this book.

Acknowledgments

This is my opportunity as author to acknowledge and thank all the people without whom this book would not be possible. I owe many thanks to Danny Carlat and the entire Carlat Publishing team for all their invaluable help with this effort, and without whom there would be no book. I must thank my family, who allowed me to take time away from them to spend on writing this. I want to thank Sidney Schnoll, my mentor, for many years of encouragement and wise advice. Finally, I should thank Joan Peck, my nurse at the methadone clinic for many years, who told me countless times that I need to write a book—well, Joan, here it is.

Chapter 1

How to Diagnose Substance Use Disorder

I used to think a drug addict was someone who lived on the far edges of society. Wild-eyed, shaven-headed and living in a filthy squat. That was until I became one . . .

Cathryn Kemp, Painkiller Addict: From Wreckage to Redemption—My True Story

Case Vignette: G is a 45-year-old woman who presents for treatment of anxiety. She was prescribed alprazolam (Xanax) by her family practitioner to take once or twice daily for severe anxiety symptoms, but she has been taking it closer to 3 times every day. She also has 2 drinks of gin before bedtime most nights, and has done this for several years. She tells me that occasionally she will get shaky during the day, and an alprazolam or a drink will steady her nerves.

WHAT IS SUBSTANCE USE DISORDER?

Before diving into the skills of diagnosing substance use disorders, it’s fair to take a step back and ask what a substance use disorder actually is. Is it a brain disease? Is it self-medication? Is it a life choice?

The answer can be any of the above, or a combination, depending on the person and the substance. For the opioid addict with overwhelming cravings who is stealing money from her friends to buy her next fix, it is primarily a brain disease involving opiate receptors. For the college student taking Adderall a couple of times a week—borrowed from friends—to study for exams and write papers, it may be a lifestyle choice (though it can devolve into neurochemical dependency if the habit becomes a daily one). For the man with social anxiety disorder who downs a few shots of vodka before going to a social event, it may be a form of self-medication.

Like most disorders in medicine and psychiatry, substance use is multifactorial, and for this same reason, it can be treated in different ways.

Neurobiology of addiction

While our knowledge of the neurobiology of addiction is limited, researchers are beginning to work out some of the mechanisms. One particular neurotransmitter, dopamine (DA), seems to play a central role for most addictions.

Most psychiatrists are familiar with DA in the setting of psychosis. All antipsychotics block DA receptors, which implies that excessive DA can be a bad thing, as it may be one of the chemicals that can cause psychosis.

However, there is another side of DA—it’s the primary neurotransmitter for the brain’s reward system. Our brain releases high levels of DA during joyful events, like graduating from high school, winning a race, or enjoying a Thanksgiving dinner. Another experience that can cause a kind of joy is abusing drugs. Cocaine and methamphetamine cause the most DA release, leading the user to feel intensely exhilarated and powerful.

While a large release of DA can indeed produce positive emotions, the brain quickly institutes measures to maintain a stable internal environment, or homeostasis. One measure is to quickly clear the DA away, which the brain does by breaking the DA down with enzymes or recycling it. But when someone is consistently using drugs, there’s too much DA for this process to work. Therefore, the brain alters itself to make the neurons a little less receptive to DA. This process is called desensitization, and it occurs in various ways biochemically, such as decreasing the number of DA receptors or slowing down receptor activation.

As the brain desensitizes to DA, the drug user experiences this as tolerance, meaning the person does not experience the same high from a given dose. If the dose is increased to compensate, the user will get high, but the brain will go through its homeostasis process again, forming tolerance to the higher dose. This is a simplistic neurobiological explanation of tolerance.

What about withdrawal—why does that happen? When there’s no external stimulation causing the brain to release DA, the user must depend on the old-fashioned process of the brain releasing DA as it normally would: that is, in response to the prosaic pleasurable events of life, like having a snack or watching a ball game. But a brain that has gotten used to relying on high levels of DA has fewer DA receptors, and those receptors are less sensitive. Therefore, the normal amount of DA doesn’t produce much, if any, pleasure compared to what the addict experiences when getting a fix. When an addict’s drug of choice is taken away, a DA deficiency results. This is one reason withdrawal is so unpleasant, and why stimulant withdrawal causes depression. With a damaged reward circuit, it becomes very hard for a user to experience normal healthy behaviors as motivating. The temptation to use drugs is extreme, because the user now feels the drugs are needed simply to feel normal. (For a review of the dopamine theory of addiction, see Nutt DJ et al, Nature Reviews Neuroscience 2015;16:305–312.)

Genetics of addiction

Drug addiction often runs in families, though the strength of the development of addiction varies between substances. Familial transmission of substance abuse does not necessarily imply genetic involvement; however, there is in fact a large amount of evidence that genes play a role.

One piece of evidence comes from studies of identical and fraternal twins. The most interesting of these studies compares these two types of twins when they have been separated at birth and put up for adoption. If addiction had nothing to do with genes, but everything to do with upbringing, one might expect that the diagnostic concordance rate of identical and fraternal twins would be the same—but in fact the identical twin concordance rate is higher. Using this kind of data, studies have estimated that the heritability of addiction to alcohol and drugs in general is 60%. This does not mean that a patient has a 60% chance of developing an addiction if one of the patient’s parents had an addiction, although this is a common misunderstanding. Instead, if a person becomes addicted, about 60% of the reason for that addiction will be genetic, while about 40% of it will be non-genetic—such as the effects of upbringing (Yu & McClellan, 2016).

If genetics has so much to do with addiction, what are some of the possible genes that play a part, and how might they work? A number of genetic variants have been identified that might contribute to increasing a person’s vulnerability to addiction. For example, genes for certain subtypes of GABA-A receptors have an association with alcohol use disorder, and a different cluster of genes is associated with a higher risk for nicotine use disorder. Other gene variants can protect against addiction. In several Asian populations, gene variants for alcohol dehydrogenase cause disulfiram-like reactions, making drinking very unpleasant. Overall, however, we’re still quite far from truly understanding the genetics of addiction, and there is no clinically useful genetic test for helping us predict who is likely to become addicted.

Case Revisited: When I ask about problems that run in her family, G reveals that her father was an alcoholic, just like his father had been. She also admits that her son has been using cannabis heavily, and that she and her husband sent him to an addiction treatment program a couple of years ago when he was in his late teens. This was a very stressful experience for her.

ASSESSMENT OF SUBSTANCE USE DISORDER

Purpose of the evaluation

When you are evaluating patients for addiction, it’s helpful to keep in mind these three common types of patients:

The treatment seeker. This patient comes to you explicitly for substance use treatment, and is willing to lay all the cards on the table to get better. The evaluation will be straightforward and aimed at ascertaining information to build the best treatment plan.

The treatment willing.This patient comes to you for a psychiatric issue, and is also abusing substances. However, the patient doesn’t consider the substance abuse a problem—not because of denial but more because of ignorance about the potential mental health effects. You will have to work a little bit harder to get the patient’s substance history, but it won’t be too difficult, because the person is not trying to hide anything from you.

The hider.This patient is willfully abusing substances and wants to continue doing so. The person may come to you for treatment of a separate psychiatric issue, or might just be in your office to score some scheduled drugs. Hiders are difficult patients and require the most skill and intuition for a good evaluation.

The questions you ask and the approach you take will differ depending on the type of patient you suspect you are dealing with. In all cases, you’ll want to obtain the following information:

What substances is the patient using, how much, and how often?

How is the substance use negatively affecting different aspects of the patient’s life? How severe is the problem? The severity informs lots of treatment decisions, such as how difficult detoxification will be, whether detox should occur in the inpatient or outpatient setting, and what kinds of referrals for adjunctive treatment you should be making.

How motivated is the patient to decrease or discontinue drug use? Does the patient believe there is a problem? This is crucial because a big part of treatment is harnessing and increasing the patient’s internal motivation to get on track to a substance-free life. You need to find out where the person is in terms of desire for treatment.

What type of treatment has the patient had in the past, and what helped? Through what is called treatment matching, you’ll try to match the severity of the disorder with the least restrictive treatment environment that is likely to be effective. For example, someone with no psychosocial support and a lot of physical withdrawal symptoms would probably not be a great fit for outpatient treatment. In contrast, if you have a patient with a supportive family and low levels of physical tolerance, then individual outpatient counseling may be a good option.

Screening questions: General tips

At some point in your initial psychiatric interview, you should plan to do a thorough screen for drug use. The launching point for that screen will vary. It might be during the first few minutes, while the patient is giving an introduction and explaining the reason for the appointment. If drug use figures prominently in the initial history of your patient’s present illness, you can start your substance screening then. Alternatively, if you typically ask about health habits, like smoking or drinking coffee, you could start the screening questions there. You can also make the transition less organic and simply plan to talk about it a bit later in the interview, once you’ve had a chance to build rapport.

Before diving into the specifics of particular substances, however, it’s important to recognize that substance use questions are tough to ask—and for patients to answer. People are embarrassed to admit to using drugs, partly because they worry others will see it as a personal weakness or defect. In that sense, it’s not much different from the stigma that accompanies any psychiatric disorder. But substance use carries legal ramifications as well. People are concerned about being arrested or about losing jobs, child custody, or driving privileges, among other things.

For all these reasons, you should be sensitive in broaching this subject. My approach is to try to normalize substance use as much as possible. I want to reassure the patient that I consider substance use a common behavior—one that is defensible and sometimes almost expected in some situations. Here are some tips on introducing the topic of substance abuse:

If the patient is describing depressive symptoms, I might say, Different people get relief from symptoms in different ways. What sorts of things have you tried for your depression? Patients will usually tell me that they’ve taken antidepressants, had therapy, or used some type of self-help strategy. I’ll follow that up with, Some people have found relief in other ways, such as using marijuana to help calm down or lifting their mood by using a stimulant or alcohol. Have you tried something like that and found it to be helpful, or not helpful? This gives patients permission to describe some non-mainstream approaches they may have taken. I might also say, Some people taking a prescription medication for one reason find that it helps with their mood or with other symptoms. Have you ever noticed anything like this?

If you’re transitioning to the drug screen part of an appointment, one way to make the transition is to say, I’m going to ask questions about different drugs you may have used. Asking about substances is not just for the initial evaluation, of course. If you’ve been seeing a patient for a while and there hasn’t been the kind of progress you would expect, you might suspect that substance use is playing a part. You can ask, How often over the past month have you gotten a buzz? Explain to the patient that drug or alcohol use might be interfering with progress in terms of symptom management.

Screening questions for specific substances

I recommend starting with the more socially accepted drugs and gradually working your way to the more stigmatizing. I often start with smoking because it’s socially accepted. Here are some sample questions that you may want to use based on substance type:

Nicotine

This one is simple: Do you smoke? If patients say yes, I’ll ask when they started, how much they use, and so forth. If they say no, I’ll follow up with, Have you ever smoked? and, When did you last smoke? Surprisingly, some people who consider themselves nonsmokers will respond with, I last smoked two days ago. While they may believe they are out of the woods because of a very recent quit attempt, we know that relapse rates are high, and this is important information to gather.

Caffeine

You can introduce the topic of caffeine by saying, Let me get an idea of your health habits. Do you drink coffee, tea, or soda? If patients say no, that’s quite unusual, and I’ll want to know why, because usually it’s a health reason; if so, I praise them for a good health decision. After asking about typical caffeinated beverages, I move on to energy drinks, which can be stigmatizing: "Do you