1. DR. FORRY J.BEN PSYCHIATRIC RESIDENT 1DR. FORRY J.BEN 2015

2.  OVERVIEW  AETIOLOGY  MANAGEMENT & PREVENTION  POTENTIAL RESEARCH AREAS  REFERENCES DR. FORRY J.BEN 20152

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4.  Last stage in motivational interviewing  10-40% enroll into formal Rx program (Kaplan & Sadock’s synopsis of psychiatry, 9 th ed)  60% chance of sobriety for ≥1year (Lewis et al, 2000)  Severe drug problems 1. I.V drug use 2. Cocaine use disorder 3. Amphetamine use disorder 4. Homeless DR. FORRY J.BEN 20154

5.  Antisocial personality disorder  Substance use co-morbidity  Major psychiatric co-morbidity  General life instability (≤20% effect) (Kaplan & Sadock’s synopsis of psychiatry, 9 th ed) DR. FORRY J.BEN 20155

6.  Poor compliance & adherence to intensive (initial) rehab course(2-4weeks)  ≤1year of abstinence  Alcohol Withdrawal syndrome (1-3%) (Kaplan & Sadock’s synopsis of psychiatry, 9 th ed) DR. FORRY J.BEN 20156

7.  Intangible factors 1. Motivational levels 2. Quality of social support systems DR. FORRY J.BEN 20157

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9.  BioPsychoSocial model  Repetitive & Passive  Motivation for abstinence  Importance of abstinence  Readjustment to free-alcohol lifestyle  Day-to-day support systems & coping styles  Rx of alcohol withdrawal syndrome DR. FORRY J.BEN 20159

10.  Intensive phase  2-4wks  Goals 1. Optimizing physiological function 2. Maximizing psychological function 3. Enhancing motivation 4. Ensuring family support & involvement  Maintenance phase  3-6months  Characteristics 1. Less frequent OPD care 2. Combines individual & group counselling 3. Self-help groups e.g. AA 4. Psychotropic meds avoidance DR. FORRY J.BEN 201510

11.  Naltrexone  Acamprosate  Buspirone*  Disulfiram  Benzodiazepines*  National Institute for Health and Clinical Excellence, 2011.  Placebos DR. FORRY J.BEN 201511

12. DR. FORRY J.BEN 201512 OBSESSIONCRAVINGCOMPULSION

13.  NALTREXONE  P.O 25mg o.d; maintenance dose 50mg o.d  ≥6months (benefits Vs desires)  Monthly monitoring; as a motivational aid & LFTs ▪ Elderly ▪ Obesity  Halt Rx if no abstinence after 4-6wks DR. FORRY J.BEN 201513

14.  ACAMPROSATE  666mg t.d.s (max daily dose 1998mg)  If ≤60kg; 1332mg max daily dose  ≥6months (benefits Vs desires)  Monthly monitoring ▪ LFTs ▪ Motivational aid  Halt Rx if no abstinence after 4-6wks DR. FORRY J.BEN 201514

15.  DISULFIRAM  Alcohol-sensitizing agent  Start 24hrs after last alcoholic drink  Usually 200mg daily  1wk with no effect = consider increasing dose  Monitoring ▪ 2wkly for 1 st 2months, then monthly for 4months ▪ Serum electrolytes ▪ LFTs ▪ Urea ▪ Pregnancy ▪ Hx of severe mental illness ▪ CVS diseases DR. FORRY J.BEN 201515

16.  Most commonly available  Greater abstinence  Contraindications  Individuals adverse to the disease model of addiction  Those whose spiritual beliefs and/or lifestyle are in conflict with the 12-step philosophy DR. FORRY J.BEN 201516

17.  CBT  Expectations  Attributions  Appraisals  Beliefs  Informs other techniques  As commonly used as 12 step group therapy  Usually one-60mins session per week for 12 weeks DR. FORRY J.BEN 201517

18.  focuses on responses to high-risk situations  Combines skills-training with cognitive interventions to prevent or limit relapse.  44-70% relapse (Pickens et al, 1985)  Hence integration is key DR. FORRY J.BEN 201518

19.  8wk OPD program  Lower relapse rates  Decreases cravings  Increases acceptance  Acting with awareness  Integrates core aspects of RPT with other forms of mindfulness-based therapies  MBSR  MBCT for depression DR. FORRY J.BEN 201519

20.  Aftercare approach for pts who recently completed an intensive treatment for substance use disorders.  “paying attention in a particular way: on purpose, in the present moment, and non- judgmentally” DR. FORRY J.BEN 201520

21.  Increased awareness, regulation, and tolerance of potential precipitants of relapse  In the event of a lapse, awareness and acceptance fostered by mindfulness may aid in recognition and minimization of the blame, guilt, and negative thinking that increase risk of relapse  Identification of high-risk situations remains central to the treatment DR. FORRY J.BEN 201521

22.  Relapse risk and protective factors assoc with neurobiologic factors & mgt of psychiatric symptoms.  Env’tal and social contexts for persons with co-occurring disorders.  RPT more broadly conceptualized & focused on lifestyle change and recovery rather than simple substance use or abstinence  5HT 3 receptor antagonists like Ondansetron  GABA-minergic Topiramate DR. FORRY J.BEN 201522

23. 1. Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences, clinical psychiatry. 9 th ed/Harold I. Kaplan, Benjamin J.Sadock. c 1998. 2. Lewis DC, McLellan AT, O’Brien CP, Kleber HD. Drug dependence, a chronic mental illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284:1689– 1695.[PubMed: 11015800] 3. Pickens R, Hatsukami D, Spicer J, Svikis D. Relapse by alcohol abusers. Alcohol Clin Exp Res.1985; 9:244–247. [PubMed: 3893196] DR. FORRY J.BEN 201523

24. DR. FORRY J.BEN 201524