Duel Diagnosis Is there anything new

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Duel Diagnosis Is there anything new?

• Critical basics
• Sobriety is critical to accurate diagnoses

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Basics

• Cannot make an accurate diagnosis in face of
  recent substance use
• Time frames can serve as a guideline but tends
  are more important
• Patients may worsen before they get better after
  prolinged meth use
• As little as twice per month use of meth may
  maintain a psychosis

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Adult children of addicts

• Dont talk dont feel
• Must shut down emotions to survive
• No models of consistency
• Higher risk of addictions
• Higher likelihood of being involved in abusive
  relationships

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Personality disorders

• Is it a true personality disorder or simply a
  drug induced behavior
• Ie are crimes committed solely to procure the
  drug
• Addiction requires dishonesty and narcissism

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Post acute withdrawal

• Is it the old dx surfacing or brain dysregulation

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paw

• Period of marked emotional instability with sleep
  disturbance
• Address sleep issues
• Look out for emerging diagnoses

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SLEEP

• eliminate caffenated beverages after noon
• No exercise near bedtime
• Natural choices
• Passion flow tea
• Chamomille tea
• Mellatonin
• Valerian root

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Pharmaceuticals

• Rozerum
• Trazadone
• Sedative sleepers are reasonable based on
  severity
• Ie ambien
• Lunesta
• Benedryl generally not recommended

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Recognizing new diagnoses

• Adhd
• Underdiagnosed
• Present with increased frequency in all sub use
  disorders highest in stimulant disorders
• 40 per cent of adhd children go on to cont to
  have symptoms that impair them in adulthood

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Adhd 2

• Active genetics
• 30 percent co- occurrence with one parent with
  the disorder
• Tends to be marked by hx of early positive
  response to stimulants before deterioration
• Hx of poor and recurrent problems with jobs
• Successful employment is usually in jobs with
  loose bounderies

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Adhd 3

• Pts will worsen in recovery if not treated
• Options for treatment include
• Strattera-non stimulant
• Adderall
• Ritalin
• Stimulants
• Most pts dont abuse their meds
• Watch closely

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Bipolar spectrum

• Mixed mania/dysphoric mania mimics PAW
• Little sustained emotional stability
• Rapid and frequent changes in mood
• With bipolar two the hypomanic episodes may be
  very brief and may just have episodes of anger
  that are dysproportionate to the event
• Depressions are more clear
• Attempt to get a pre use hx of MI

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Bipolar treatments

• For the most atypical bipolar conditions mood
  stabilizer vs atypical antipsychotic or both are
  preferable
• For bipolar 2 reasonable to see pt on mood
  stablizer plus antidepressant or
• Two mood stabilizers
• Or atypical plus mood stabiliers

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Who are the suspects

• Mood stabilizers
• Depakote
• Tegetol(trileptal)
• Lithium
• Atypicals with mood stabiliziing
  capabilitiesabilify,seroquel,zyprexa and
  geodon,clozaril

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Whats new in depression

• Medications that increse serotonin help with
  modulation prevent ocd,panic gad and depression
• Medications that increase norepinephrine increase
  energy
• Meds that increase dopamine improve alertness
  concentration and initiation

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Implications of Star d study

• Large depression study designed to test
  effectiveness of antidepressants starting
  everyone out on celexa

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Results and implications

• Only 33 percent remitted in 14 wks
• 17,24 and 21 percent improved when switched to
  zoloft,effexor and wellbutrin respectively and
  over 20 percent improved when wellbutrin was
  added
• Implication is that usually the first
  antidepressant is not effective and we must be
  aggressive

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Other controversies

• IS it ok to treat while pt is decreasing use?
• Implications for marijuana use and intermittent
  cr use
• Benzo use is it dependence or addiction
• (Xanax,valium ativan klonopin)
• Dos and dont of benzo detox

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Other new medsand their use

• Buphrenorphine
• Suboxone and subutex
• Anticraving alcohol drugs
• Campral
• Naltrexone
• Vivatrol(long acting injectable naltrexone)

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Addiction in complicated populations

• HIV
• HEP C

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Alchohol dependence

• Presence or absence of Genetic hx
• Implications for pharmacological treatments
• Is treatment effective?

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Attitudes regarding medications

• No, all medications are not bad medications
• Please do not allow your own biases stand in the
  way of proven treatments
• Important to give realistic explanations of what
  to expect from meds.
• Older recovering staff may be resistent

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Pharmacological treatments

• Campral
• Probably works by dampening glutamate response.
  Most effective after a few days of sobriety
• Dose is cumbersome 333 mg tid for a week then 666
  mg tid

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Naltrexone

• Felt to be more effective in alcholics with
  stronger genetic hx
• Blocks opiate receptor and blunts reward response
  to alcohol
• Comes as long acting monthly injection in form of
  Vivatrol

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Opiate dependence

• Heroine
• Dilaudid
• Vocodan
• Norco
• Oxycontin
• fentanyl

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Opiate replacement

• Methadone
• Down side is long acting and has linear kinetics
  ie the more you take the more negative effects
  occur
• Buprenorphine ( suboxone,subutex)
• Excellent newer replacement expecially good for
  oral opiate dependence

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Methadone pts

• Check your own emotional response
• Only situation in chemical dependence that
  maintence is acceptable due to harm reduction
  model
• Encourage treatment for hep c
• New evidence shows hep c virus is neurotoxic and
  has demonstrable effects on concentration and
  memory independent of elevated ammonia fromliver
  failure

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THANKS

• Work hard play hard go to Kaui
• Be patient
• Be nonjudgemental
• Stay humble
• LISTEN!!!