1. Specific Program Issues 11am to 12:30 pm Session Young Adult Addiction Young Adult Psychiatric

2. Young Adult Addiction Once the addict discovers that using a substance provides pleasure, he has set up a Biological Conditioned Response. Any unpleasant or boring situation - he can get immediate relief. This response overrides any concerns about the consequences of using this substance (driving intoxicated, unsafe sex, stealing)

3. Genetically Prewired 8.5 percent of the general population meet the criteria for substance abuse and dependence You have to be genetically prewired to drink a fifth of vodka a day or to be mentally organized, motivated, and alert on 120mg of Roxycodone per day. 18 to 25% of young adults meet the criteria for a substance use disorder Frequent excessive binges in order to deal with anxiety or depression may be the reason for the increase but there are other factors

4. Addiction is a Medical Disorder the Limbic System does not care about consequences of actions. Its only purpose is to respond to a negative stimulus before you have time to think. The Cortex is that part of our brain that remembers all past consequences of behaviors. Its purpose is to assess the risk by reviewing what you have learned before you act.

5. Immaturity and Impulsivity Drugs and alcohol used in high doses disconnect the cortex from the Limbic system The limbic system is totally developed by the age of 18 yo but the cortex is still maturing until 25 yo. The young adult who is genetically prewired to be an addict and is active in his addiction, has limited impulse control for multiple reasons. He is an accident ready to happen.

6. “Imprinting” Most opiate addicts can tell you the first time they experienced their first opiate. It takes one pill for the limbic system to choose opiates as the answer to all problems. It takes a year to replace it with recovery. The limbic system is the source of primitive drives and it is in the driver’s seat for an addicted young adult. The cortex is in the back seat making suggestions.

7. Better Opiates for Pain Oxycontin in the 90’s was a tremendous advancement as a more effective pain medication with less side effects. Availability of opiates dramatically increased giving chronic pain suffers relief. As the street price of these drugs have increased, it is cheaper to use heroin. Heroin has become more available with the increase demand.

8. Opiate Epidemic Dramatic increase in the # of young adults out of work, not married, unemployed, living with their parents, loss of purpose. Opiates readily available which gives a sense of wellbeing and stops all worries for 8% of population. Young adults with time on their hands plus opiates = an epidemic Over past 10 years opiate use has increased multifold.

9. Opiate Dependency is a Lethal Disease 7 patients died after discharge from the program from 2009 through 2013 All had diagnosis of Opioid Dependence One had done very well in the program and completed the program and went to a ¾ way house 5 left the program before recommended or were administratively discharged

10. The Other Drugs Alcohol Marijuana Xanax Cocaine Synthetic Drugs “Spice” – Synthetic Marijuana “Bath Salts” – Stimulant which causes delusions and hallucinations

11. Withdrawal Acute Withdrawal Syndrome (3 to 7 days) - Primary – Alcohol, Benzodiazepines, Opiates - Other – Marijuana, Stimulants, Ecstasy Post Acute Withdrawal Syndrome(1 to 6months) - Sleep, limited Frustration tolerance, anxiety, depression, cravings, high relapse potential, “I am never going to feel good again!”

12. Relapse Relapse as a concept Patients have many relapses in terms of going back to old addictive behaviors before they relapse on their substance Relapse on the addictive drug -First use initiates the cravings -Second use solidifies it -Third use is large amount – OD and death After a relapse the main focus is, “What are you going to do about it!”

13. Special Treatment Considerations Naltrexone and Vivitrol – Opiate and Alcohol -Cravings -Minimize Relapse -Dedication to the recovery process Klonopin and Xanax -Withdrawal Seizures – Depakote -Probable Anxiety Disorder Chronic Pain - Cymbalta, Neurontin, Lyrica, Muscle Relax

14. Eating Disorder – “Dual Diagnosis” Tract -Bulimia – The substance addiction cannot be treated unless you are treating the Bulimia Sexual Addiction - Multiple sexual encounters - Pornography/Internet Post Traumatic Stress Disorder - ? 20% - <10% Dissociative

15. Specific Treatment Challenges Arrested Development - #1 cause is Marijuana 1 – Social, emotional, and spiritual 2 – Ego development has “pieces” missing 3 – Partially adult and partially adolescent Many patients have been smoking marijuana daily for 3 to 5 years. You do not have to be genetically prewired to be a daily marijuana user.

16. Psychiatric Disorder is #1 Relapse Risk Factor 90% of the Addictive patients have a separate Psychiatric Disorder Anxiety is the largest disorder followed by Depression 90% of the addiction patients do not have a Personality Disorder 90% of the patients that say they have ADHD do not have this disorder. Many patients in the program are diagnosed with a Psychiatric Disorder for the first time.

17. Medications that cause Relapse Mood altering Medications – Benzodiazepines (Xanax, Klonopin) – Opioids (Roxy, heroin, Oxycontin) – Tramadol (Ultram) – Suboxone/Subutex – Amphetamines (Vyvanse, Adderall, Ritalin) – Ambien, Lunesta, Restoril, Halcion and Benadryl – Provigil/Nuvigil – Soma

18. Hardest to Treat Methamphetamine addiction -Cravings are hard and constant - Wellbutrin - Dopamine -Post Acute Withdrawal symptoms has to be aggressively managed medically Daily Suboxone use greater than 3 months. IV heroin use greater than 6 months

19. Our Population at Ridgeview Random sample of 50 admissions in 2011 – 35% left AMA or Administratively – 35% were referred to extended treatment – 30% completed program and followed recommendations – ~70% had primary dx of Opiate Dependency

20. ~1/3 of all patients have dx of Marijuana Dep. ~1/3 - Xanax Dep. ~15 to 20% of patients – Alcohol Dep/Abuse <10% – All other substances >50% have at least two or more Drugs >10% are addicted to anything they can abuse and they should prob. not be on any medication unless absolutely necessary

21. 2012 Outcome Study Included all patients who completed the program in 2012. Out of those we could contact: 57% in recovery 43% had relapsed at least once ~90% had a dual diagnosis ~90% had to be “incentivized” to start

22. Young Adult Psychiatric (My best guess) 10 to 20% stay in Ridgeview residence Primary diagnosis is Major Depression and Generalized Anxiety Disorder Next in frequency is Bipolar Disorder I and II 15% have Borderline Pers.Dis. 10% first Psychotic episode/Schizophrenia 30% have criteria for Addiction Dependency 10% purge, self mutilate 20% drink alcohol and smoke marijuana

23. Aggressive medication treatment - Relief of symptoms but limited side effect - Psychosis, suicide, withdrawal may need inpatient We try to manage abuse of drugs, self mutilation, and purge but ------ Education of parents is critical to be able to do interventions

24. Bipolar Disorder Differential diagnosis includes - Post Traumatic Stress Disorder - Borderline Personality Disorder - Steroid use/abuse, Accutane, amphetamines, cocaine, antidepressant - Head injury or brain tumor - Hyperthyroidism Non-compliance with meds Alcohol, marijuana, sedative use

25. Medical Treatment Depakote - #1 most used mood stabilizer 85% no side effects but Sedation, weight gain, cognitive slowing Rarely liver damage Antipsychotics – #2 most used Risperdal, Abilify, Zyprexa, Seroquel, Geodon Lithium - #3 most used Only one that helps antidepressant Only medication to stop recurrent Suicide

26. Schizophrenia Schizophrenia and Schizoaffective Disorder average age of onset is 17 yo (13 to 25). Primary Symptoms – Delusions, hallucinations Negative Symptoms – Autism-like, amotivational behavior Issues are compliance, use of alcohol and drug Much more violence with non-Schizophrenics It usually takes parents a year to finally accept this diagnosis so do not get frustrated with them.