Efficacious Physician-Patient Relationships Or Physician, Therapist and Patient Relationships Elliot S. Cohen, M. D. M. L. Grabill, M.Ed. PsychiatristLicensed Professional Counselor Licensed Addiction Counselor

Areas of Interest: 1. Health Care Changes 2. Creativity and Comments on a mutual Bipolar Patient (CB Art) 3. Behavioral Health Care Professional Relationships 4. Working with the Opiate Addicted Patient

Changes in health care and how it will affect all of us (As EC sees it)  Change from sickness/disease model to preventive medicine model  The medical home and communication  Only the sickest patients will see a physician  Reimbursement patterns: “Goodbye fee for service”

Physician/Therapist Issues in Communicating  Is the therapist competent and experienced in their field of work?  Is the therapist flexible to adapt the treatment to the patient? (One size does not fit all)  Will the therapist provide notes and documentation to the medical doctor, so the MD can incorporate them into the treatment plan?  How will the MD provide pertinent information to the therapist?

 Does the therapist realize the legal risk MD assumes when sending patients for treatment? (Captain of Ship Liability)  There are only 24 hours in the day; can the therapist help the MD within the time constraints of the practice?  Does therapist have experience and the ability to treat dual diagnosis?  Can the therapist be trusted to make an accurate diagnosis of DSM IV pathology when referring patients initially?  Does the MD want to provide teaching “moments” and vice versa?

Further thoughts on Physician/ Therapist relationship  Can we find time to get together to get to know each other? (lunches, sponsored lectures. conferences, etc)  Be persistent with MD, be an advocate for your client- but avoid “splitting”.  Ok to challenge the MD on their treatment and as a therapist, be open to be challenged back.

Audience participation of their specific problems / issues in working with physicians: Therapist/Counselor personal stories Tidbits for counselor successes Frustrations Client success

Working with the Addicted PDMP  Colorado Prescription Drug Monitoring Program  Available to all physicians  Monitor frequently  Counselor role?

Blocking agents for craving/abstinence  Buprenorphine  Probuphine (6 Month injecttion)  Naltrexone  Vivitrol  Vaccines  Role of Counselor

Neurobiology of Addiction Significance of:  MD is the “expert”  What should Therapist know?  Learning process

 Dopamine is the main player in the reward / dependence pathway that has a major role in intense craving

 Gene expression changes, induced by substance dependency, causes a different neuro-physiologiacal state of demand thus a physiological balance. Provoking drug seeking behavior upon substance withdrawal.

 In addition to genetic aberrations that motivate the imitation of the substance abuse, exposure to opiates may cause alterations in gene expression which changes normal state of neurotransmitter production.

A comprehensive outpatient treatment program  Monthly visits with physician  Count pills / films monthly (each film has an ID number)  Significant other (spouse/parent) hold medication to keep it safe  Random urine analysis 4-6x monthly  Work with one or two pharmacies  Weekly therapy

 AA/NA 2 or 3 times a week  Group therapy  Periodic checks of the Colorado Prescription Drug Monitoring Program (PDMP)

Statistics from SAMHSA 2010/2012  Estimated 9.0 million people age 12 or older use illicit drugs other than marijuana Among those a majority 5.1 million were non medical use of pain relievers and estimate 200,000 were using heroin  As of April 2012 there were 23,052 waiver physicians for Buprenorphine.(maximum case load of 40 patients) 5,865 were authorized to treat up to 100 patients  In 2011 close to one million individuals received buprenorphine prescriptions

Medications for addiction  Most existing addiction medications work buy targeting the same receptors as the addictive drug. Agonists or partial agonists such as opioids methadone and buprenorphine, relieve cravings by stimulating the same receptors as the abused drug, but at a lower level.

 Antagonist drugs, on the other hand, act at the same receptors to block the drugs effect. This is the principle behind the opioid antagonist, naltrexone, which is used for treating addiction to opioids as well as alcohol. Compliance has always been an issue with naltrexone for opioid addiction. But with Vivitol, an injectable long-acting formulation of naltrexone, which can be administered just once a month in a doctors office, there is no need for daily dosing.

Explanation:  “A metaphorical switch in the brain seems to be thrown as a result of prolonged drug use. Initially, drug use is a voluntary behavior, but when the switch is thrown, the individual moves into a state of addiction, characterized by compulsive drug seeking and use.” [Leshner, A]

Further Explanation:  “ At some point after continued repetition of voluntary drug-taking, the ‘user’ loses the voluntary ability to control its use. At that point, the ‘drug misuser’ becomes ‘drug addicted’ and there is a compulsive, often overwhelming involuntary aspect to continuing drug use and to relapse after a period of abstinance.” [O’Brien and McLellan]

More Explanation:  “A primary behavioral pathology in drug addiction is the overpowering motivational strength and decreased ability to control the desire to obtain drugs…Cellular adaptations in prefrontal glutamatergic innervation of the accumbens promote the compulsive character of drug seeking addicts by decreasing the value of the rewards, diminishing cognitive control (choice), and enhancing glutateric drive in response to drug-associated stimuli.” [Kalivas and Volkow]

Summary:  Future Health Care Issues  Working Together as a Clinical Team which includes the Patient  Listening  Learning  Collaboration  Gaining more knowledge  Do no harm