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AOD Course Intro Sep 2010.ppt

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Presentation Slides & Transcript

Presentation Slides & Transcript

Assessment and Treatment of Alcohol and Other Drug ProblemsJoan E. Zweben, Ph.D.Executive Director East Bay Community Recovery Project, Oakland, Ca.Clinical Professor of Psychiatry; University of California, San

Social Costs of ATOD UseTobacco: 443,000 deaths/yr., $193 billion (CDC, 2009)Alcohol: 100,000 deaths/yr., $98.6 billionOther drugs: $67.4 billionTOTAL COSTS: $238 billion per yearEstimate: 25% of national health care budget spent treating conditions related to ATOD

ETSEnvironmental Tobacco SmokeThird leading cause of preventable death (after active cigarette smoking and alcohol)Class A carcinogen (like asbestos, radon)32,000 – 40,000 deaths due to heart disease3,000-4,000 lung cancer deathsSingle most important air contaminant in the workplace (Osinubi & Slade, 2002)

How Costs ManifestIncreased criminality, court costs, incarcerationSocial service system utilizationUnderemployment, absenteeism, decreased productivity, accidents, violenceHealth: heart disease, AIDS, hepatitis,TB, STD’s, neonatal complications, etc.

How Costs Manifest (2)Substance-dependent persons use health care services up to 10 times the rate as non-addicted personsFamily members use these services at a rate up to 5 times that of families of persons with no substance use disorder

Total State Budget in 2005 (in millions)Elementary and Secondary Education $101,996Substance Abuse and Addiction $47,644Medicaid $16,331 Higher Education $9,829Transportation $6,772Population 36.5 million

When Treatment is Under Financed The Budgeted Substance Abuse DollarWho Picks Up the Actual Cost

Evaluating the Effectiveness of Addiction TreatmentsOUTCOME DOMAINS:Reduction of alcohol and other drug useImprovement in personal and social functionReduction in public health and safety threats (McLellan et al, 1996)

Treatment Outcome Indicatorsreduction/elimination of illicit drug usereduction/elimination of criminal activityimprovement in health statusimprovement in psychiatric statusimproved family functioningimproved educational/vocational functioning

Treatment OutcomesUp to 4 decades of researchA variety of types of research is neededEvidence-based principlesEvidence-based practicesBig gap in implementation researchBuild infrastructure to obtain practice-based evidence

Important DistinctionsEvidence-based principles and practices guide system development Example: care that is appropriately comprehensive and continuous over time will produce better outcomesEvidence-based treatment interventions are important elements in the overall picture. They are not a substitute for overall adequate care.

Evidence-Based PrinciplesRetention improves outcomes; we need to engage people, not discharge them prematurely.Addicts/alcoholics are a heterogeneous population, not a particular personality type.Addiction behaves like other chronic disordersProblem-service matching strategies improve outcomes. (Other matching strategies disappointing.)Harm reduction approaches yield benefits in terms of public health and safety.Pts in methadone maintenance show a higher reduction in morbidity and mortality and improvement in psychosocial indicators than heroin users outside treatment or not on MAT.

Policies and Practices Not Supported by ResearchRequiring abstinence as a condition of access to substance abuse or mental health treatmentDenying access to AOD treatment programs for people on prescribed medicationsArbitrary prohibitions against the use of certain prescribed medicationsDischarging clients for alcohol/drug use

Evidence-Based Practices Random Assignment Controlled TrialsGold standard for pharmacological and many psychosocial interventionsExamples with strong efficacy: Cognitive behavioral therapyMotivational enhancement therapyCommunity reinforcement approachContingency management approachesRelapse preventionSocial skills training (see Miller et al, 2005)

Cost Benefit Data$1.00 invested in treatment saves $5.00 in health care costs$1.00 saves $11.50 in combined medical, social, criminal justice costsCALDATA (California Study): $1.00 saves $7.00

Policy Decisions: System Issuesseparate funding streams perpetuate barrierssaving money in one system often results in higher costs in anotherno central accountabilityproviders organize systems around their own limitations, vs promote integrated treatmentgoal: AOD issues are addressed in whatever system patient appears

“It took me 10 years to get off using drugs, and I was a member of the US Congress and I was an attorney and I was white and I was middle class. Don’t turn your back on people who have had drug problems.” STATE SENATOR JOHN BURTON, D-SAN FRANCISCO, IN OPPOSING A BILL FOR A LIFETIME BAN ON WELFARE BENEFITS FOR DRUG FELONS. IT WAS APPROVED.

Treatment & Recovery IAddiction tx is funded and evaluated as an acute care intervention (AC Model)Crisis-linked points of interventionBrief durationFocus on symptom suppression (abstinence)Professionally dominated decision-makingExpectation of full and permanent problem resolution (William White, 2008)

Addiction & Recovery IIChronic disorder model works better (like diabetes, asthma, hypertension)Does not necessarily mean a prolonged course requiring professional treatmentFull recovery is possibleSelf-management responsibilities are very important (William White, 2008)

Recovery-Oriented Systems of Care (ROSC)Grass roots advocacyDisillusioned fundersResearch data on limitations of AC modelPositive evaluations of RM modelGood results from pilots (Connecticut, Philadelphia) (William White, 2008)

Emergent IssuesPrescription Drug AbuseGamblingAnabolic Steroids

Number of new non-medical users of therapeutics

Annual Numbers of New Nonmedical Users of Pain Relievers: 1965-2002Fig5.3All AgesAged Under 18Aged 18 or OlderThousands of New Users

Lifetime Nonmedical Users of Selected Pain Relievers among Persons Aged 12 or Older: 2002 and 2003Fig2.4Numbers of Lifetime Users (in Millions)Vicodin®,Lortab®,or Lorcet®Percocet®,Percodan®,or Tylox®Hydro-codoneTramadol,  = Significant change 2002 to 2003Any Pain RelieverOxy- Contin®Methadone

Addiction vs Pseudoaddiction IAddictionInability to follow prescribed scheduleMultiple doses taken togetherFrequent loss or stolen prescriptionsDoctor shoppingIsolation from family and friendsInsistence on rapid onset formulationsNo relief from from non-opioid medicationsNegative consequences! (David Kan, MD, 2007)

Addiction vs Pseudoaddiction IIPseudoaddictionBehaviors related to under-treated symptoms:Focused on obtaining medications“Clock-watching”Drug seeking behaviorResolves with adequate symptom treatmentMay continue to use drugs to stave off withdrawal (David Kan, MD, 2007)

Untreated Pain Longer recovery from surgeryHigh levels of hormones can stress the heart and lungsCan cause blood pressure to spike, leading to heart attacks and strokesDegrades immune system by consuming energySuicide

Problem GamblingPathological gamblers lie, cheat or steal to keep playing; many adverse consequences3-5% become problem gamblers who cannot stopIndicators: crime, bankruptcies, lost workdays, domestic violence, illness, divorce, etc.Social costs outweigh benefits 3:1 (Grinols 2004)

Anabolic SteroidsInformation Website)

DescriptionHuman-made substances related to male sex hormonesUses:Medical conditions (e.g., wasting syndrome)Performance enhancers for athletesImprove appearance

Use PatternTaken orally or injectedCycles of weeks or months – take multiple doses over a specific period of time, stopping for a period, starting again“Stacking” – combining several types of steroids to maximize effectiveness while minimizing negative effectsMost users are male

Side EffectsCancer, esp liver and kidney tumorsJaundiceHigh blood pressureSevere acneTremblingHalting of growth in adolescents, possibly permanently

Side Effects: MalesShrinking of testiclesBreast developmentReduced sperm countIncreased risk for prostate cancerBaldnessInfertility

Side Effects: FemalesGrowth of facial hairMale pattern baldnessChanges in or cessation of menstrual cycleEnlargement of clitorisDeepened voice

Psychiatric Side EffectsExtreme mood swingsManic symptoms leading to violenceDepression when drugs are stoppedParanoid jealousyExtreme irritabilityDelusionsImpaired judgment stemming from feelings of invincibility

Characteristics of Substance Abuse Treatmentmultidisciplinary; teamwork with other professionals (medical, social services, criminal justice)eclectic intervention repertoire necessarypsychoeducational component essentialability to work with families and groups important

Conceptual Models of AddictionMoral modelDisease modelLearning theory Classical conditioningOperant conditioningCognitive-behavioral model (CBT)Affect regulation modelFamily modelsBiopsychosocial model

Biopsychosocial Model of Addiction There are multiple pathways to AOD disordersEtiology, maintenance and progression are influenced in different ways by each componentMust assess and plan treatment to address all levels