Treatment of Substance Abuse Herbert D. Kleber, MD Professor of Psychiatry Director, Division on Substance Abuse Columbia University/NYSPI Note: session devoted mainly to cases. (Aspects of Treatment for background purposes) Aspects of Treatment. Addiction: a chronic relapsing disease. Characterized by: COMPULSIVE drug seeking and use Control is eroded but not erased Use in spite of consequences—physical, psychological, social… Treatment Principles: Kleber’s 9 Commandments 1. Treatment works—but not as often or as well as we would like. ―Treatment CAN work.‖ 2. All treatment works—for someone! The critical issue is, however, is it for 5% or 50% of the population and who are they? We need patient-treatment matching. 3. No one treatment is effective for all drug abusers—the heterogeneity of the population requires a variety of approaches. There is no one ―best treatment‖ Diabetes analogy. Some responds to diet alone, some to oral hypoglycemics, and some to insulin. We don’t think any less of the third group than we do for the first two groups. Anyone who tells you they have the treatment is lying (as said last week) to you, themselves, or both. 4. Some addicts need rehabilitation—others need habilitation. No ―re‖ to go back to. Rehabilitation: a lawyer with a good practice, a family, good insurance, social support. Habilitation: a 20 year old who has no vocational skills, family has thrown him out, bad interpersonal skills, education, etc., no ―re‖ to go back. Such an individual might need long term therapeutic community. 5. Treating psychiatric problems will not cure the addiction. The old way of thinking was that treating psychiatric problems would cure the addiction. Conversely, as AA postulates—the psychiatric problems are due to the addiction, you treat the addiction, you treat the psychiatric problems. The reality is that you need to treat both. Relapse will be more probable if you don’t.
6. Legal coercion into treatment (involuntary treatment) works about as well as voluntary—as long as it’s voluntary. People need to choose even if the choice is a draconian one—even if it looks involuntary from the outside. Person should be given a choice between treatment and jail, for example. They can feel that they have chosen. How many of them actually prefer jail? (Some actually feel that jail is easier than the treatment communities…) 7. Effects of in-prison treatment will decay unless followed by after care. Self help programs can be an important resource both in prison and in the community. AA. But by themselves, often not enough. 8. In general, longer duration in treatment associated with better outcome, as long as it’s the right treatment. If the person is in the wrong treatment, it won’t work. 9. Work is important to long term abstinence. You don’t want to give them too much time to do nothing. Skilled, well-compensated jobs are better than their opposite, but some work is better than no work. You need some reason to get out of bed in the morning, some reason to keep you occupied. [Posting of a cartoon with a guy crawling in the desert, dying of thirst] Sometimes, the 12 step approach isn’t adequate. ―Sorry, no water, we’re just a support group.‖ Water=use of meds, other kinds of psychiatric interventions. The best set of treatments are for opiate addiction: opiate Addiction Pharmacotherapy. Agonists—Methadone (LAAM taken off the market, caused cardiac arrhythmias, Torsade de pointes) Partial Agonists—buprenorphine Antagonists—naltrexone Antiwithdrawal—a whole variety of ways to detoxify people Craving, esp. related to stress—alpha adrenergic agonists, like clonadine erlophexanine Heroin treatment admissions and heroin purity in NYC are closely related. Heroin purity has gone up drastically (less than 20% pure to now 50-80% pure). Increase in people in NYC seeking treatment for heroin. About 50% seeking detox now are not injecting but snorting, because of its potency and cheapness. Methadone Maintenance. Advantages: Blocking opiate use without euphoria Decreased criminality Improved health Disadvantages: Include not blocking cocaine (50% also abuse) or alcohol abuse (20% also abuse) Difficult withdrawal
Frequent lack of comprehensive services. o Over the last decade, programs have been going from not-for-profit to private for-profit (nationally, 60%, and in CA, 90%) o How to make a profit: cut staff. o A perfectly good medication being delivered in poor staff support settings.
Naltrexone Opioid antagonist approved by FDA in 1994 Blocks opioids without agonist effects, no euphoria. You need to be off narcotics to begin with You can abruptly stop this drug without withdrawal You can take it for years without getting tolerant to its effects Ideal drug but patients are uninterested because it doesn’t really do anything, just blocks. Buprenorphine. Partial agonist. Advantage over methadone because of its ceiling effect: if you take too much, you don’t die, no respiratory depression Can be given in office-based setting. Just approved by FDA a few years ago. Commissioner of Health in NYC says, as there are currently only 40000/200000 treated narcotic addicts in the city, that by 2010, he hopes 100000 in treatment, and a lot of this hopefully through expansion of buprenorphine. Treatment of Heroin addiction. Residential Therapeutic community. eg. Phoenix House Very high success rate. Especially useful for criminal addicts. Unfortunately most addicts choose not to go there because it takes 12-18 months. Very successful but a relatively low graduation rate. In terms of other treatments, there are no good treatments for cocaine, so basically it’s psychological with marijuana, we’ve tried a number of drugs, and some are promising… CASES: (with comments from Dr. Gunderson, internal medicine). The clerkship: Physical therapist with liver transplant team at Milstein Hospital. Patients: Heavy alcohol users, many had used IV drugs. Job of physical therapist: Working on patient mobility pre and post surgery, to improve outcome.
Mr. C. 38 yo male Hepatitis C. Had been in hospital for 2 weeks, had jaundice and ascites. He was in a great amount of pain all the time, and also had tubes draining his abdomen that made getting up really painful. End stage liver transplant patient. Anyone must be substance free for 6 months to be clean enough to receive a new liver. Frequent visits with psychiatrist and social worker. 1. Why is 6 months the given time period? 2. How difficult is it for a doctor to watch a patient who hasn’t met the six month limit yet is incredibly sick and promises to reform? Hepatitis C virus is most common blood-borne infectious disease 1.8% serum prevalance. Many Hepatitis C patients develop chronic hepatitis cirrhosis, and this is attributed to 40% liver transplants nationally. Alcohol is a very important, modifiable risk factor that hastens progress of disease from Hepatitis C to end stage liver disease. Why the 6 month wait? National shortage of livers. 1. People who are actively drinking would be less compliant with immunosuppressive regimen necessary to keep the liver healthy. 2. Alcohol contributes to disease progress in a Hepatitis C-infected liver. Patients’ new livers would very likely also be infected with Hepatitis C. Why specifically 6 months? Prospective study of 55 liver transplant patients. All had Hx of alcohol related serosis. Relapse over 1 (11%) and 2 years (30%), also amount had per week. Among 10 drinks/week group, 11% relapse by 1 year, 22% by 2 years. So what factors could predict progression into relapse? The only independent predictor for alcohol relapse was the 6 month period of abstinence—23% v. 79%. How difficult must it be for patient who promises to reform? 5 month window. And what is the value of a promise to reform (since seriously ill patients make a lot of promises)? National standard is 6 month window. Extremely young patients going to die because not having 6 month window. Some staff sent them to University of Pittsburgh, which, in the late 1990’s, didn’t have a six month window requirement. Balance between this and shortage of livers for transplant as well as probability of relapse. The 6 month window is for getting on the LIST. How do you determine whether the patient is alcohol-free? Communication with treatment providers, working with outpatient treatment program, checking toxicology, checking alcohol levels weekly…
Case 2: the difference between physical dependence and substance addiction. 10 year old patient, pediatric oncology, with acute myelogenous leukemia for 4 years. Addiction to opiates, his analgesic. Presents withdrawal symptoms. Chronic pain, struggle regarding pain meds. Why is it that there is such difficulty in managing pain? We don’t want our patients to suffer, but we also don’t want to be their drug suppliers. This boy is important in looking between physical dependence and substance dependence or addiction. Hallmarks/characteristics of addiction. He is a chronic pain patient who is PHYSICALLY dependent on this opiate. Physical dependence. Is their tolerance? Is there withdrawal symptoms? What is withdrawal from opiates? Painful, deep bony pain, from thighs, lower back, or diffuse, like severe ab. cramps, diarrhea, extreme anxiety, etc. When PCA pump removed and he showed withdrawal symptoms PCA pump, high level opiates, to nothing, that’s really hard. In general, a much longer gradual taper is required for milder withdrawal symptoms. We don’t know much about the status of this disease. Progressive? His increased pain could be either tolerance or disease progression. PCA excellent for pain relief. People who have them actually take fewer pain meds. Switching to a subcutaneous pump? The challenge is figuring out the difference between physical dependence and addiction. How do you do when you have adequate pain relief? Are you able to do the things you need to do on a daily basis? How do you manage someone who’s not an adult? Is he able to go to school? Can he go play games, do the 10 year old things he needs to do? If the person is more of a chronic pain patient Studies on iatrogenic addiction in oncology patients being treated for pain is REALLY LOW. Terminal progressive disease, special case. Again, emphasis that dependence is different from addiction. In this individual, it’s cruel and bad medical practice to not treat for pain. Historically, students and doctors are dreadful of treating pain. Such a fear that ―we’re going to addict people‖ that we let them suffer from pain, etc. If they do become dependent, we can withdraw them, etc. Sometimes we don’t take into account how long the drug actually lasts. Example. Demerol, Q 4 hours, although lasts for three hours. They’re going to be complaining in 3 hours. Case 3. Project Renewal. People with 15-25 year addictions to crack, etc. Ben’s first patient EVER.
26 yo male college graduate, successful friends, in homeless shelter. He’s paranoid schizophrenic, in and out of institutions for several years. Does he use any recreational drugs, marijuana, used to smoke every day, but now he is abstinent? What made him want to quit? When he smokes, all he wants to do is sleep, when he wakes up, all he wants to do is smoke again, becomes a cycle, he thinks the world is going to end... What makes him start the cycle again? Sometimes he wakes up and just feels like starting the cycle over again. Doing things that are not in our best interest. Relationship between marijuana and schizophrenia. ―Marijuana: no longer a harmless giggle.‖ –reference to John Lennon. Now, much more potent drug, kids starting the drug much younger… 1. If you already have schizophrenia, marijuana use increases paranoia, current of hallucinations, destabilize individuals on medications. 2. Before you become schizophrenic. Studies indicate that heavy users are diagnosed 7 years before individuals who don’t use marijuana. What’s not clear is marijuana bringing on volatile state, or is it someone who was going to get it anyway, etc. 3. Suicidal ideation. Individuals with serious suicide attempts 17x more likely to be marijuana users than a control group. Also, he might have been using marijuana to self-medicate early symptoms. Can temporarily relieve anxiety. Adolescent brain is much more vulnerable. No fourth case…