1. Chemical Addictions — General Overview Abdullahi Mubarak, MD Medical Director of Addiction Services at PEMCO Chief Medical Officer at Consortium Clinical Services, LLC

2. Objectives Understand general terminology The disease of Addiction Symptoms of the disease Stages of change Diagnostic tips General treatment approaches

3. Terminology Use—drug taking not associated with harm Abuse—drug taking associated with harm Dependence—adaptation to drug evidenced by normal functioning and/or withdrawal syndrome Addiction—loss of control, compulsion, continued use despite adverse consequences

4. Terminology Abuse potential—the likelihood that a person will abuse a drug based upon it’s pleasurable effects, toxicity, and society’s attitude toward the users of the drug Addiction potential—the likelihood that a drug will produce addiction in chronic users

5. Relative Addiction Potential Cocaine (crack, IV, snorted, chewed) Methamphetamine (smoked) Nicotine (IV, smoked, chewed) Opiates (IV, smoked, snorted, chewed, oral) Alcohol Sedative-hypnotics Anabolic steroids Marijuana Inhalants PCP, other hallucinogens (LSD, Special K, )

6. Disease of Addiction Addiction is primarily a function of many genetically predisposed biological responses. The response and/or lack of the drug reinforces the repeated use of the drug. The environment permits and facilitates the use of the drug. Addiction can be “created” in low risk patients with chronic use of drugs of high addictive potential.

7. Progression of the Disease Erratic drug-taking pattern, erratic sleep, work, eating, grooming, and social habits New forms of enjoyment, new “friends”, ways of relating, isolation, hiding money, hiding whereabouts, lying Legal, financial, marital, social, career, and lastly physical adverse consequences

8. Stages of Change Pre-contemplation—lacks awareness Contemplation—ambivalent about change Preparation—getting information in order to change Action—actually committing to sobriety in deed Maintenance—attaining stability Recovery—sobriety Relapse—use leads to return to contemplation

9. Signs of Aberrant behavior Prescription forgery Concurrent abuse of illicit drugs Selling prescriptions Recurrent lost, stolen, or spilled drugs Stealing or borrowing from others Obtaining drugs from non-medical sources Obtaining scripts from multiple doctors

10. Indicators of Suspicion Reluctant to present identification “Out of town” patient Overly willing to pay cash Telephone call in for controlled substances Presents when the regular physician cannot be reached

11. Indicators of Suspicion Allergy to NSAIDS, COX-2’s, or codeine Intolerant to collateral contacts Intolerant to in-depth interviews Interested only in the drug, not the diagnosis Reluctant to comply with diagnostic testing, pill counts, and urine screening

12. Factors Less Indicative Drug hoarding during periods of decreased symptoms Unsanctioned dose escalation Request for specific drugs by name Focus on opiate issues during the first three office visits

13. Abnormal Physical Signs Pupils 6.5mm in room light Presence of nystagmus Diminished or absent corneal and/or pupillary light reflex Impaired convergence Pulse 100/min Venosclerosis or needle tracks Perforated nasal septum

14. Characteristics of the Pain patient Appreciates in-depth interviews Cooperates with attempts to get collateral histories Cooperates with pill counts and urine drug screening Focus is on the diagnosis and the cure Attempts to reduce medications on their own Cooperates with diagnostic and therapeutic interventions

15. Addressing Aberrancy and indicators of suspicion Obtain an INSPECT report Urine drug screen (UDS) Use oral salivary testing when urine screening is unavailable, patient unable to void, or the UDS is invalid Pill counts when appropriate Use Axis V outline to clarify your thoughts Treat ONLY according to your diagnosis

16. INSPECT reports The report is unconfirmed history until you confirm what’s in it. “Multiple prescribers” means nothing until you call the providers to find out what they did, why they did it, and did they know there were other prescribers Keep the interpretation of the report in your chart

17. Urine drug screening The results only mean what the results say Using them to make a diagnosis is only part of the total picture Refer for addiction consultation, if the results are aberrant Negative screens can mean abuse, addiction, diversion, or pseudo-addiction syndrome Do not collect without temperature strips on the cup. Be sure the reference lab tests for validity and multiple metabolites

18. Oral Salivary Testing Easy to use, less intrusive Shorter window of detection compared to urine drug screening Accuracy comparable to blood testing The results only mean what the result says

19. Pill Counts Best when used sparingly or unexpected Best to clarify negative urine drug screens Order within 2 days to rule out diversion Order within 10 days to rule out abuse or addiction Pills can be brought to office or the pharmacy they purchased their pills Record any markings on the pills for identification

20. Diagnostic Challenges Impaired by lack of knowledge of differential diagnosis Impaired by EMOTIONAL reactions to the “names” of controlled substances Use Axis V outline to highlight deficiencies in knowledge or when you are becoming too emotional Say “NO”, if the request is inappropriate for the diagnosis or you have inadequate information to arrive at a diagnosis Continue to monitor to confirm or deny your provisional diagnosis. Being wrong is ok.

21. Consultation Learn the biases of your consultants. Psychiatry consultation for benzo and stimulant prescribing for mood disorders, ADHD, etc… Addiction consultation to evaluate aberrancy Pain management consultation to evaluate opiate prescribing

22. General treatment principles Foremost goal initially is self-diagnosis Educate—Addiction is a disorder in a person, not the pill Medication assistance—diminish drug craving, withdrawal, and normalize function Intensity of treatment related to intensity of use pattern and/or history of treatment failures Strengthen social/spiritual supports