THE PSYCHOLOGY OF SUBSTANCE RELATED

DISORDERS

Raymond Zakhari, DNP, EdM, ANP-BC, FNP-BC, PMHNP-BCDepartment of Internal Medicine in Psychiatry

New York Presbyterian Hospital Weill Cornellwww.RaymondZakhari.com

www.MetroMedicalDirect.com

How to Assess & Provide Appropriate Care

Definitions Drugs, Effects & Consequences Statistics Professional Responsibilities Treatment Options

Key Terms Dependence: indicates an altered

physiologic state caused by repeated administration of a drug the cessation of which results in a specific syndrome

Terms continued Abuse: use of any drug, usually by self

administration, in a manner that deviates from approved social or medical patterns

Misuse: usually applied to prescribed medications that are not used properly

Addiction The repeated and increasing use of a

substance or behavior, when deprived, causes symptoms of distress, and an irresistible urge to use the agent or engage in the behavior again despite consequences (physical, social, legal).

Withdrawal A substance of the specific syndrome that

occurs after stopping or reducing the amount of substance that has been used regularly over a prolonged period characterized by physiological and psychological signs and symptoms. Also called abstinence syndrome or

discontinuation syndrome

Tolerance A physiological phenomenon which

occurs after repeated consumption of a drug producing decreased effect despite increasingly larger doses to achieve the first affect. Behavioral tolerance reflects the ability to

perform tasks despite the effects of the drugs

Cross-tolerance The ability of one drug to be substituted

for another each usually producing the same physiological and psychological effects Benzodiazepines and barbiturates

Neuro adaptation: Neurochemical changes in the body that result from the repeated administration of a drug which accounts for the phenomenon of tolerance

Codependence Friends or family members affected by

the behavior of a substance abuser, facilitating the abusers addictive behavior, requires the unwillingness of a family member to accept addiction as a medical psychiatric disorder, and denial that a person is abusing the substance. Enabler

Denial A primitive defense mechanism

characterized by an unwillingness to accept ego-dystonic obvious circumstances.

Epidemiology 22 million people older than the age of 12

were classified as having a substance related disorder 10% of the total US population

(National Institute of Drug Abuse 2012)

21 million (9.3%) people are diagnosed with diabetes in the United States (CDC 2012)

Who are the 22,000,000? 15 million were dependent on or abuse

alcohol 669,000 people were dependent on or

abused heroin 4.3 million abused marijuana 1 million abused cocaine 2 million were classified as dependent on

or abused pain relievers

22 million Those who use any substance younger than

15 years of age for more likely to become addicted than those who started at a later age

Of Adults 21 and older who first tried alcohol at age 14 or younger 15% were classified as alcoholics 3% who first used alcohol at age 21

Men > Women| Whites > Blacks| Higher Edu. > Lesser Edu.| Unemployed > employed

Etiology It depends on the individual and the

circumstances It requires drug availability & social

acceptability Likelihood is increased with peer pressure and

initial experimentation experience Addiction determinant: is influenced by

personality, individual biology, actions of the drug

Brain Disease From voluntary to compulsive Classic theories: substance abuse is a

masturbatory equivalent (heroin users describes the initial rushes similar to a prolonged sexual orgasm)

Defense against anxious impulses or a manifestation of oral regression

Disturbed Ego function: inability to deal with reality (self-medication).

Factors influencing addiction Behavior maintained by

its consequences Genetic factors: twin

studies suggested a component for alcoholism

Neurochemical factors: Receptors and Receptor Systems

Pathways and neurotransmitters comprise the brain reward circuitry Dopamine, GABA,

Opioids

Brain Reward Pathway

Other Neurotransmitters

Insightful Diagnosis and Treatment

Diagnostic ClassificationSUBSTANCE USE DISORDER: a maladaptive

pattern of use leading to significant impairment or distress as manifested by 2 or more of the following occurring within a 12 month period

Failure to fulfill major role obligations

Recurrent use and situations in which physical hazard may occur i.e. driving

Continued use despite having persistent or recurrent social or interpersonal problems exacerbated by effects of the substance

Tolerance developed Withdrawal Increasing use Persistent desire or

unsuccessful efforts to cut down

Giving up important activities for the substance use

Continued use despite knowledge of persistent and recurrent physiological problems

Craving to use

Substance Withdrawal A substance

specific syndrome resulting from the abrupt cessation of heavy or prolonged use of a substance

The development of a syndrome due to the cessation or reduction in substance use that has been heavy

Syndrome that causes clinically significant distress or impairment

Symptoms are not due to a general medical condition or another mental disorder

Corollary & Comorbid Antisocial

Personality Disorder

Mood Disorders Anxiety Disorders Suicidality Delirium Psychosis Dementia

Sleep Disorders Sexual Dysfunction Amnestic Disorder Intoxication Flashbacks Cognitive

impairment Encephalopathies

Cannabinoids Hashish, Marijuana How Consumed: swallowed, smoked Effects: euphoria, slowed thinking and

reaction time, confusion, impaired balance and coordination

Consequences: cough, frequent respiratory infections, impaired memory and learning, increased heart rate, anxiety, panic attacks

Depressants Barbiturates, Benzodiazepines, GHB, Rohypnol,

Quaalude How Consumed: swallowed, injected Effects: reduced anxiety, feeling of well-being,

lowered inhibitions, slowed pulse and breathing, lowered blood pressure, poor concentration

Consequences: fatigue, confusion, impaired coordination, memory, judgment, respiratory depression and arrest, death

Dissociative Anesthetics

Ketamine, PCP How Consumed: Injected, swallowed, smoked,

snorted Effects: increased heart rate and blood pressure,

impaired motor function, delirium, panic, aggression

Consequences: memory loss, numbness, nausea/vomiting, depression

Hallucinogens LSD, Mescaline, Mushrooms How Consumed: swallowed, smoked Effects: increased body temperature, heart rate,

blood pressure, loss of appetite, sleeplessness, numbness, weakness, tremors, altered states of perception and feeling, nausea

Consequences: persisting perception disorder (flashbacks)

Opiods Codeine, heroin, morphine, opium,

Oxycodone, Hydrocodone How Consumed: injected, swallowed,

smoked, snorted Effects: pain relief, euphoria, drowsiness Consequences: nausea, constipation,

confusion, sedation, respiratory depression and arrest, unconsciousness, coma, death

Stimulants Amphetamine, cocaine, MDMA,

methamphetamine, nicotine, Ritalin How Consumed: injected, smoked, snorted,

swallowed Effects: increased heart rate, blood pressure,

metabolism, feelings of exhilaration, energy, increased mental alertness

Consequences: rapid or irregular heart beat, reduced appetite, weight loss, heart failure, nervousness, insomnia

Assessment Open-ended questions

Motivational Interviewing BATHE technique

Obtain releases for/ from all other providers

Maintain active communication with providers

Observations: MSE and Physical exam findings

R.U.L.E. Resist the righting reflex

Psychological reactivity & Therapeutic Paradox Understand your patient’s motivation

Why would they want to? Listen to your patient

Equal parts of listening & informing Empower your patient

Help in contemplating the how and why

How to refer for evaluation It sounds like you may benefit from

talking to someone Provide 2-3 referrals Provide the patient with reassurance that

you are referring to a resource you trust

Reflective Listening

Validate & Affirm

Explore a Menu of Options

Explore the Pro’s and Con’s

Where are they on the SOC continuum?

Ask permission

Set an Agenda

Ambivalence is Normal

Resist the Righting Reflex

Consider life balanceHigh Risk Situations

Explore Coping

Create Discrepancy

Readiness to Change?

What is the motivation

Abstinence Violation Effect

Empathy

Promote Self-Efficacy

Use Rulers

What’s Next?

Listen for and try to do these things:

Types of treatment available

Abstinence vs. harm reduction Detoxification Outpatient Intensive Outpatient Inpatient

28/ 30-day Long-term residential

Half-way house Anonymous meetings

Relapse Prevention Model

Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct

Relapse Prevention High Risk Situations Self-Efficacy Abstinence Violation Effect (AVE)

Raymond Zakhari The Adult Health Nurse Practitioner of New York, LLC Metro Medical Direct

Craving mediated by Expectancies For immediate effect

Rationalization,Denial, and apparently irrelevantdecisions

Lifestyle imbalance(Shoulds> wants) Desire for

indulgence or immediate gratification (I owe myself)

Precursors to High Risk Situations

High Risk Situation

Coping Response

No Coping Response

Increased Self-Efficacy

Decreased Self-Efficacy

Decreased probability of relapse

Lapse

Abstinence Violation Effect

Relapse

Cognitive Behavior Model of the Relapse Process

HIGH RATES OF RELAPSE:

Negative Emotional State (35%)

Interpersonal Conflict (16%)

Social Pressure (20%)

Cummings, Gordon, & Marlatt 1980; Marlatt & Gordon 1980

Abstinence

Functionality inFamily, Work,

and Community

Goals of Drug Treatment:Keeping an Eye on the Target

Reduced Criminal Behavior

Drug addiction is a brain disease that affects behavior.

Brain changes in addiction help explain continued drug abuse and relapse.

Relapse Rates for Drug Addiction are Similar to Other Chronic Medical

Conditions

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100

Drug Dependence

Type I Diabetes

Hypertension Asthma

40 t

o 60

%

30 t

o 50

%

50 t

o 70

%

50 t

o 70

%Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

Perc

ent

of P

atie

nts

Who

Rel

apse

Drug Abuse Treatment Can Work

• No single treatment is appropriate for all individuals.

• Treatment needs to be readily available.

• Treatment must attend to multiple needs of the individual, not just drug use.

• Multiple courses of treatment may be required for success.

• Remaining in treatment for an adequate period of time is critical for treatment effectiveness.

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Pre During Post

Treatment Research Institute

Outcome In Diabetes

Conclusion: Treatment Successful!

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Pre During Post

Treatment Research Institute

Outcome In Addiction

(Incorrect) conclusion: Treatment NOT successful!

Intake Processing / Assessment

Treatment Plan

Pharmacotherapy

Continuing Care

Clinical and Case Management

Self-Help / Peer Support Groups

Behavioral Therapy and Counseling

Substance Use Monitoring

Detoxification

Child Care Services

Vocational Services

Medical Services

Educational ServicesAIDS / HIV

Services

Family Services

Financial Services

Legal Services

Mental Health Services

Housing / Transportation

Services

Services to Match Needs

Treatment should target factors associatedwith criminal behavior.

Criminal thinking Antisocial values Anger/hostility Problem solving Conflict resolution skills Attitudes toward school/work Mental health problems Family functioning Barriers to care Alcohol/drug problems

Treat co-existing mental disorders in an integrated way.

DRUG ABUSEDepression

Attention Deficit Disorder

Conduct Disorders

Bipolar Disorder

Post-Traumatic Stress Disorder

Medications are an important element of treatment.

Methadone

Naltrexone

Buprenorphine

Useful Websites www.al-anon.alateen.org www.alcoholics-anonymous.org www.na.org www.nida.nih.gov www.samhsa.gov www.niaaa.nih.gov www.fadaa.org

THANK YOURaymond Zakhari, NPTwitter: @RZakhari

#AddictCareNYCwww.RaymondZakhari.com