December 10, 2015 Arthur Robin Williams MD MBE American Academy of Addiction Psychiatry Division on Substance Abuse Department of Psychiatry, Columbia University New York State Psychiatric Institute Clinical Management: Alcohol Use Disorders

 NIAAA website has many resources   Free 16-page booklets  g/OrderPage.htm g/OrderPage.htm

Other Psychotherapy - CRA - RPT -TSF Family Therapy Patient Behavioral - CBT - MI/MET - CM Medications (MAT) - AA/NA - Self-help - Smart Recovery AUD Treatment Options Level of Care: - Outpatient - Individual - Program - Residential - Inpatient/ Hospital Level of Care: - Outpatient - Individual - Program - Residential - Inpatient/ Hospital

Other Psychotherapy - CRA - RPT -TSF Family Therapy Patient Behavioral - CBT - MI/MET - CM Medications (MAT) - AA/NA - Self-help - Smart Recovery AUD Treatment Options Level of Care: - Outpatient - Individual - Program - Residential - Inpatient/ Hospital Level of Care: - Outpatient - Individual - Program - Residential - Inpatient/ Hospital - Detoxification - Aversion - Anti-Craving - Substitution

- Excessive amounts used - Excessive time spent using/obtaining - Tolerance - Withdrawal Problematic use despite - Physical hazards - Health problems - Missed obligations - Interference with activities - Interpersonal problems - Craving or urges to use - Unsuccessful attempts to cut down 11 Symptoms of Addiction

Addiction & Problematic Use Addiction: chronic disease needs treatment − Up to 16% of the 12+ population Problematic use: − Substance use that threatens health & safety − Does not meet addiction criteria − Up to 32% of the 12+ population Both require medical care 6

Addiction & Problematic Use SBIRT: Screening, Brief Intervention, Referral to Treatment All patients diagnosed with addiction should receive treatment All patients with problematic use should receive a brief intervention 7

 Neuropathology  Anti-glutaminergic  Potentiates GABA  Dopamine release Alcohol

- Excessive amounts used - Excessive time spent using/obtaining - Tolerance - Withdrawal (not all substances) Problematic use despite - Physical hazards - Health problems - Missed obligations - Interference with activities - Interpersonal problems - Craving or urges to use - Unsuccessful attempts to cut down Targeting Symptoms Medication s (MAT) - Detox taper (Librium or Methadone)

MAT: Alcohol Detoxification (Youth typically binge drink and rarely require) Use benzodiazepines, phenobarbital Outpatient v. inpatient models Aversion Antabuse 250mg or 500mg daily (FDA 1951) Start after all alcohol has cleared Can dose on site or have observer at home Effects for up to 2-3 weeks for some Consider as an adjunct to psychosocial therapies Monitor liver function every 1-3 months

- Excessive amounts used - Excessive time spent using/obtaining - Tolerance - Withdrawal (not all substances) Problematic use despite - Physical hazards - Health problems - Missed obligations - Interference with activities - Interpersonal problems - Craving or urges to use - Unsuccessful attempts to cut down Targeting Symptoms Medication s (MAT) -Aversion (Antabuse) - Anti-Craving (Naltrexone)

MAT: Alcohol Anti-Craving Campral 666mg TID (FDA 2004) – Stabilizes neuroexcitability in protracted withdrawal – Dosing is problematic (but no side effects) – Better choice for patients with liver disease Naltrexone 50mg daily (NTX) (FDA 1994) – Reduces number of drinks per drinking day and cravings – Side effects limited (nausea/sedation) – LFTs should be followed intermittently (every 3 months) Vivitrol 380mg IM (XR-NTX) (FDA 2006) – Long acting monthly injection of naltrexone

 MAT includes  Antabuse (disulfiram) 250mg or 500mg daily  Naltrexone 50mg+ daily or monthly Vivitrol injection  Acamprosate 666mg PO TID  Dosing should be observed by family or program  Check liver function regularly if on naltrexone or Antabuse Summary: Alcohol

 If pill taking not witnessed, assume not taken  Patients often “fail” naltrexone on path to antabuse  Roll with resistance if patients attempt “moderation”  SMART Recovery is an alternative to AA/NA  Treating anxiety and sleep is key in first few months  CBT, behavioral treatment:  Sedating anti-depressants, gabapentin, etc. Clinical Tips: Alcohol

 CBT for Insomnia:  Niederhofer, H. and W. Staffen (2003). "Acamprosate and its efficacy in treating alcohol dependent adolescents." Eur Child Adolesc Psychiatry 12(3):  Niederhofer, H. and W. Staffen (2003). "Comparison of disulfiram and placebo in treatment of alcohol dependence of adolescents." Drug Alcohol Rev 22(3):  Simkin, D. R. and S. Grenoble (2010). "Pharmacotherapies for adolescent substance use disorders." Child Adolesc Psychiatr Clin N Am 19(3): References