1. ` Integrating: 12-Step Spirituality, 21 st Century Psychopharmacology, Addiction Psychiatry, and Dual Diagnosis Concepts In Addiction Treatment Settings By GARRETT O’CONNOR, M.D. The Radisson-Miyako Hotel San Francisco October 8-11, 2003 ADDICTION MEDICINE: STATE OF THE ART 2003

2. ` ADDICTION IS A BRAIN DISEASE

3. ` THE RE-ENTRY OF PSYCHIATRY INTO THE ADDICTION TREATMENT FIELD

4. ` ADDICTION IS A CUNNING POWERFUL BAFFLING DANGEROUS DEVIOUS UGLY & HIDDEN DISEASE

5. ` BUT MORE THAN A DISEASE, ADDICTION IS A WAY OF LIFE

6. ` RECOVERY IS ALSO A WAY OF LIFE

7. ` ADDICTION IS THE GREAT IMITATOR OF ALL DISEASES (Especially Psychiatric Ones)

8. ` INTOXICATION CAN MIMIC OR OBSCURE: Panic Disorder Anxiety Disorder Major Depression Psychotic Disorder Bipolar Disorder Drug-Induced Organic State Obsessive Compulsive Disorder Chronic Alcohol/Drug Use Attention Deficit Disorder

9. ` DUAL DIAGNOSIS The Co-occurrence of a Substance Use Disorder and a Psychiatric Disorder (Major Mental Illness Or Severe Personality Disorder In the same Person)

10. ` DUAL DIAGNOSIS Is Important Because of: Its Arguably High Prevalence, (b) Its Prognostic Significance (c) The Important Rx. Implications of Making a Correct Diagnosis

11. ` THE DIFFERENTIAL DIAGNOSIS BETWEEN CO-OCCURRING PSYCHIATRIC DISORDERS AND ADDICTIVE DISEASE IS A VITAL CLINICAL DETERMINATION!

12. ` DANGER! Prescribing Psychotropic Medications for the Wrong Diagnosis Failure to Prescribe PsychotropicMedications for the Right Diagnosis

13. ` A MISTAKE EITHER WAY CAN LEAD TO EVENTUAL RELAPSE AND EVEN DEATH!

14. ` INTEGRATING TWO POTENTIALLY ANTI-THETICAL MODELS “12-STEP” (BPSS) ABSTINENCE, SPIRITUALITY SERVICE, HIGHER POWER, BIG BOOK AUTHORITY, GROUP CONSCIENCE. “PSYCHIATRIC” DUAL DIAGNOSIS, MEDICAL AUTHORITY, PRESCRIPTION AUTHORITY, PSYCHOTHERAPY, PSYCHIATRY AS HIGHER POWER.

15. ` I2-STEP ORIENTED TREATMENT PROGRAMS MUST NOT ALLOW BIOLOGICAL PSYCHIATRY, SCIENCE, AND PSYCHOTROPIC MEDICATIONS TO BECOME THEIR HIGHER POWER

16. ` A BALANCED APPROACH IS ESSENTIAL

17. ` IT’S REALLY AN ORGANIZATIONAL CULTURE PROBLEM!

18. ` CULTURE: Shared beliefs and values of a group: The beliefs, customs, practices, and social behavior of a particular nation, class or group of people.

19. ` INTEGRATING FIVE CULTURES ACTIVE ADDICTION ABSTINENCE-BASED TREATMENT AND 12-STEP SPIRITUAL RECOVERY COGNITIVE-BEHAVIORAL TREATMENT DYNAMIC PSYCHIATRY BRAIN RESEARCH & BIOLOGICAL PSYCHIATRY

20. ` EACH ONE OF THESE FIVE CULTURES HOLDS DIFFERENT, AND OFTEN CONFLICTING, BELIEFS ABOUT THE NATURE OF ADDICTION, AND HOW IT SHOULD BE TREATED

21. ` THEREFORE, THE NATURE, TASK, ROLE, BOUNDARIES, AND AUTHORITY OF EACH CULTURE MUST BE DEFINED, UNDERSTOOD, AND ACCEPTED

22. ` FOR EXAMPLE, DIFFERENTIATE TREATMENT FROM RECOVERY!

23. ` DIFFERENTIATE ABSTINENCE FROM HARM REDUCTION FROM CONTROLLED DRINKING

24. ` SOME “DIFFICULT” ELEMENTS OF 12-STEP SPIRITUALITY

25. ` THE SPIRITUAL CONCEPT OF A HIGHER POWER

26. ` ACCEPTANCE AND SURRENDER

27. ` THE INFLATED ALCOHOLIC EGO MUST BE DEFLATED AT DEPTH (Bill W.)

28. ` SELECT AND SUBMIT TO A SPONSOR

29. ` SERVICE IN AA COMMITMENTS 12-STEP WORK WORK WITH NEWCOMERS H & I G.S. REPRESENTATIVE SPONSORSHIP CENTRAL OFFICE

30. ` SOBRIETY IS AN UNNATURAL STATE FOR ADDICTS

31. ` SOBRIETY IS THE #1 CAUSE OF RELAPSE

32. ` GIFTS FOR RECOVERING ALCOHOLICS (Opportunities for Spiritual Growth) Suffering! Humiliation! Disappointment! Disillusionment! Betrayal! Loss! Extreme Guilt & Shame! Abandonment! Failure! Success!

33. ` THE SPIRITUAL VALUE OF SUFFERING

34. `

35. ` THE RE-ENTRY OF PSYCHIATRY INTO THE ADDICTION TREATMENT FIELD

36. ` ABOUT 50% OF ALCOHOLIC/ADDICTS ADMITTED TO THE BETTY FORD CENTER ARE ALREADY ON PSYCHOTROPIC MEDICATIONS PRESCRIBED BY PCP’S OR PSYCHIATRISTS, OFTEN WITHIN 3-6 MONTHS PRIOR TO ADMISSION

37. ` SCIENTIFIC EVIDENCE FOR ADDICTION AS A BRAIN DISEASE NEW EMPHASIS ON THE DUAL DIAGNOSIS CONCEPT AGGRESSIVE TV AND OTHER MASS MARKETING OF SSRI AND OTHER PSYCHOTROPIC DRUGS; BENZO’S ETC. AWARENESS OF POPULATIONS NEEDING TREATMENT. E.G., LICENSED PROFESSIONALS, URBAN HOMELESS ETC.

38. ` PSYCHIATRY AND PHARMACEUTICAL COMPANIES BELIEVED THEY COULD ENHANCE THE EFFECTIVENESS OF 12-STEP TREATMENT & RECOVERY FROM LATE 80’S, MAJOR ADDICTION MEDICINE SOCIETIES (AAPA; ASAM; CSAM; Etc.) ACCEPTED “EDUCATIONAL” MONIES FROM DRUG COMPANIES

39. ` DRAMATIC BREAKTHROUGHS! NEW FRONTIERS! REVOLUTIONARY ADVANCES! EVIDENCE-BASED TREATMENT APPROACHES

40. ` DRUGS USED AFTER DETOXIFICATION IN TREATMENT OF ADDICTION Disulfiram Naltrexone LAAM Acamprosate Methadone Buprenorphine Mood Regulators Anti-depressants Sedative-hypnotics (Rarely, if ever) Anti-psychotics (When indicated)

41. ` DUAL DIAGNOSIS PSYCHOTROPIC MEDICATIONS IN RECOVERY BOO-HOO FOR 12-STEP! (NO “SCIENTIFIC” EVIDENCE!)

42. ` ON THE CONTRARY, RECENT RESULTS FROM PROJECT MATCH SUGGEST THAT AA MAY BE THE MOST EFFECTIVE APPROACH FOR LONG-TERM ABSTINENCE AND SOBRIETY

43. ` POTENTIALLY USEFUL & VALID NEW TECHNOLOGIES MAY BE EXPERIENCED BY STAFF AS THREATS TO THE 12-STEP CULTURE

44. ` AFTER DETOXIFICATION, PSYCHOTROPIC MEDICATIONS SHOULD BE PRESCRIBED FOR ALCOHOLICS AND OTHER ADDICTS IN RECOVERY ONLY WHEN THE DIAGNOSIS OF DUAL DISORDER HAS BEEN CONFIRMED

45. ` NEGATIVE ATTITUDES IN AA ABOUT PSYCHIATRISTS/PSYCHOTHERAPY INSENSITIVE DANGEROUS (ANTI-AA) ARROGANT DRUG-ORIENTED IGNORANT ABOUT ADDICTION ABUSIVE NON-SPIRITUAL MINIMIZE IMPACT OF ALCOHOL MONEY-GRUBBING COMPETITIVE CONTEMPTUOUS THREATENING

46. ` NEGATIVE ATTITUDES OF PSYCHIATRY TOWARDS AA SUBSTITUTE DEPENDENCY AA IS “ADJUNCTIVE” A FOLK MOVEMENT RELIGIOUS BIBLE THUMPING A CULT FOSTERS DEPENDENCY IN MEMBERS NO FOLLOW-UP NO CONTROLLED RESEARCH EFFICACY NOT PROVED DISORGANIZED HOSTILE TO PSYCHIATRY LACKS ACCOUNTABILITY UNCOOPERATIVE COMPETITIVE NON-INTELLECTUAL FREE

47. ` POSITIVE ATTITUDES IN AA ABOUT PSYCHIATRISTS, PSYCHOTHERAPY AND COUNSELORS GRATITUDE (38% OF AA MEMBERS SAY THEY WERE REFERRED TO THE PROGRAM BY PSYCHIATRISTS OR OTHER THERAPISTS) MANY AA MEMBERS EXPRESS GRATITUDE TO PSYCHIATRISTS FOR SUPPORT AND FOR PRESCRIPTIONS OF ANTI- DEPRESSANTS OR SSRI’S WHICH THEY SAY “GOT THEM THROUGH”,“TOOK THE EDGE OFF”, OR “MADE IT POSSIBLE FOR THEM TO STAY SOBER”.

48. ` POSITIVE ATTITUDES IN PSYCHIATRY ABOUT AA SUPPORTIVE LIFE-SAVING INDISPENSABLE DIVINELY INSPIRED COOPERATIVE COMPLEMENTARY REVOLUTIONARY ADMIRATION GRATITUDE

49. ` NEGATIVE 12-STEP ATTITUDES TOWARD MEDICATIONS A Crutch Easier Softer Way Impede Spiritual Recovery Foster Dependency Substitute for Higher Power Violate AA Traditions Bad Example for Newcomers Ill-Trained Physicians Stupid Physicians Criminal Conduct by Docs

50. ` UNDERSTANDING RECOVERY AND ADDICTION (M.BEAN) THE NATURE OF ADDICTION THE THINKING DISORDER (“STINKIN THINKIN”) THE MECHANICS & DYNAMICS OF RECOVERY THE ALCOHOLIC IDENTITY THE RECOVERING IDENTITY THE ROLE OF SPIRITUALITY IN RECOVERY AA IS NOT “AN ADJUNCT” TO PSYCHOTHERAPY

51. ` SHAME

52. ` PERSONAL, PROFESSIONAL, AND MEDICAL SHAME

53. ` PRINCIPLES FOR INTEGRATING 12-STEP AND DUAL DIAGNOSIS PROGRAMS 1.Needs Assessment 2.Establish Vision & Mission 3.Survey Staff Attitudes 4.Create Policies and Procedures 5.Educate Referents 6.Adequate Staff Education 7.Cross-Training for Staff 8.Capability for Longer Stay 9.Double Trudger’s Groups 10.Integrated or Segregated Treatment Tracks? 11.Expert Differential Diagnosis 12.Drug-free Observation Period 13.Experienced Medical and Psychiatric Direction

54. ` CRF ANTAGONISTS MAY INTERRUPT STRESS CYCLES, BLOCK DOMINO EFFECTS, AND PREVENT BIOLOGICAL CASCADING INTO DEEPER LEVELS OF STRESS

55. ` IN THE MEANTIME, EVERY ONE HOPES THAT SOMETHIHG ALREADY OUT THERE (a drug, that is) WILL BE FOUND TO BE EFFECTIVE!

56. ` URGENT NEED TO FORMALLY ADDRESS THESE CULTURAL DIFFERENCES WITHIN THE FIELD TO FACILITATE BENCH TO BED TO COMMUNITY TRANSLATIONAL INITIATIVES

57. ` THE SERENITY PRAYER God grant me the serenity to accept the things I cannot change The courage to change the things I can And the wisdom to know the difference