Pharmacological Issues in Treatment of Co-Occurring Disorders在共同发生的疾病的治疗药物的问题

Addicted,CrazyorBoth?

NowWhat?

DualDiagnosisintheCDPatientMarkMenestrina,MD,FASAMBrightonHospital/SEMCAMichiganJudges’MI8/2021Part1(the“teaser〞)AddictionReviewClassificationofMentalDisordersReviewofCommonDisordersAssociationofMentalHealthDisorderswithSUDsPart2ReviewofSelectedClassesofPsychiatricMedicationsPharmacologyforRecoverySafePrescribingforIndividualswithSUDsAddictionReviewWELIVEINAMAGICALTHINKINGMEDICATIONSEEKINGSOCIETYUSAis4.7%oftheWorldPopulationButweconsumealmost50%oftheWorld’sDrugsandmostoftheWorld’sPainMedicationMedia/TV/Radioflooduswithmessages…WearetaughtnottotolerateanydiscomfortwithouttakingsomethingtofeelbetterADDICTIONISABRAINCHEMISTRYDISEASEInvolvestheMeso-LimbicSystem(Primitive)NeurotransmitterMediated(NotConscious)DenialisaHallmarkFeatureEmotional,Physical,PsychologicalChronic,Progressive,potentiallyFatalAffectsFamily,Community,SocietyandSchools~10%aresusceptibletoAddiction…TreatableDiseaseDifferentthanAbuse,anyonecanAbuseDrugsorAlcohol.…PreventableBehaviorIT’SNOTREALLYADISEASE…ISIT?1956AMAdesignatesAlcoholismasadisease,DrugAddictionasadiseasefollowed“Butyouhaveachoice〞Likedepression30yearsago,oroncology40yearsagoComparetootherChronicDiseasesWhenwedotreatAddiction,wedosoAcutely,andwonderwhywehavepoorresults12Canyoufindthe(alleged)futurealcoholic?LACKOFWILLPOWER?13IFADDICTION/CHEMICALDEPENDENCEISTRULYADISEASE….WHYDON’TWETREATITASSUCH?LeadingCausesofDeath

DatafortheU.S.2007Age25-44InjuryCancerHeartDiseaseSuicideHomicideHIVLiverDiseaseStrokeDiabetesAge15-24InjuryHomicideSuicideCancerHeartDiseaseCongenitalStrokeDiabetesGoogle:Alcoholism+HumorThefaceofaddiction...andthefacesofrecoveryADDICTIONvs.ABUSEALCOHOLISM,DRUGADDICTION,CHEMICALDEPENDENCEATREATABLEDISEASEDRUGABUSE,ALCOHOLABUSEAPREVENTABLEBEHAVIORTHENEWGATEWAYFORMANYYOUNGPEOPLE…ADDICTIONTREATMENTMADEEASY….“A〞to“B〞NEGATIVEConsequences:Thejob,liver,judge,wife,boss,friendgettheindividual’sattention!POSITIVEReinforcement:Theindividualactuallybeginstolikeandenjoy“recovery〞Whilethisprocessisachievable,itisnotlikelytoallmakesensetothepatient.Itmayinvolve12step,counseling,treatmentofco-morbidconditions,MedicationAssistedTreatmentsandothermodalities.HOWTOSPOTAHUNTERWITHADUICONVICTION….Co-OccurringDisordersPsychiatricIllness&Addiction

GeneralizationsBotharecommonproblemsHavingoneincreasestheriskforhavingtheotherHavingonecomplicatesthetreatmentoftheotherwhenbotharepresent“DualDiagnosis〞casesareoverrepresentedamonghomelessandincarcerated“DualDiagnosis〞haveincreasedriskofHIVandotherseriousmedicalconditionsClassificationofMentalDisorders…DSM-IV-TRTheofficialclassificationsystemofpsychiatricconditionsinuseintheUSACriteriainDSMareusedtofacilitatecommunicationamongprofessionals,forresearchstandards,andfor3rdpartypayorcommunicationDSM-Amentaldisorderisadisorderwithsignificantbehavioralorpsychologicalsymptomsassociatedwithpresentdistress,disabilityorincreasedriskofsufferingdeath,pain,disabilityorlossoffreedomTHE5AXESOFDSMI.CLINICALDISORDERSII.PERSONALITYDISORDERSandMENTALRETARDATIONIII.GENERALMEDICALCONDITIONSIV.PSYCHOSOCIALANDENVIORNMENTALPROBLEMSV.GAF(GlobalAssessmentofFunctioning)ASAMDIMENSIONSI.ACUTEINTOXICATIONORWITHDRAWALPOTENTIALII.BIOMEDICALCONDITIONSIII.EMOTIONAL,BEHAVIORALORCOGNITIVECONDITIONSIV.READINESSTOCHANGEV.RELAPSEPOTENTIALVI.RECOVERY/LIVINGENVIORNMENTDSMatWork…(ornot!)

MajorDepressiveEpisodeFive(ormore)ofthefollowingsymptomshavebeenpresentduringthesame2-weekperiodandrepresentachangefrompreviousfunctioning;atleastoneofthesymptomsiseither(1)depressedmoodor(2)lossofinterestorpleasure.Note:Donotincludesymptomsthatareclearlyduetoageneralmedicalcondition,ormood-incongruentdelusionsorhallucinationsMD…continued(1)Depressedmoodmostoftheday,nearlyeveryday,asindicatedbyeithersubjectivereport(e.g.,feelssadorempty)orobservationmadebyothers(e.g.,appearstearful)Note:Inchildrenandadolescents,canbeirritablemood.(2)Markedlydiminishedinterestorpleasureinall,oralmostall,activitiesmostoftheday,nearlyeveryday(asindicatedbyeithersubjectiveaccountorobservationmadebyothers)MD…continued(3)Significantweightlosswhennotdietingorweightgain(e.g.,achangeofmorethan5%ofbodyweightinamonth),ordecreaseorincreaseinappetitenearlyeveryday.Note:Inchildren,considerfailuretomakeexpectedweightgains.(4)Insomniaorhypersomnianearlyeveryday(5)Psychomotoragitationorretardationnearlyeveryday(observablebyothers,notmerelysubjectivefeelingsofrestlessnessorbeingsloweddown)MD…continued(6)Fatigueorlossofenergynearlyeveryday(7)Feelingsofworthlessnessorexcessiveorinappropriateguilt(whichmaybedelusional)nearlyeveryday(notmerelyself-reproachorguiltaboutbeingsick)(8)Diminishedabilitytothinkorconcentrate,orindecisiveness,nearlyeveryday(eitherbysubjectiveaccountorasobservedbyothersMD…continued(9)Recurrentthoughtsofdeath(notjustfearofdying),recurrentsuicidalideationwithoutaspecificplan,orasuicideattemptoraspecificplanforcommittingsuicide.ThesymptomsdonotmeetcriteriaforaMixedEpisode(seep.171)Thesymptomscauseclinicallysignificantdistressorimpairmentinsocial,occupational,orotherimportantareasoffunctioning.MD…continuedThesymptomsarenotduetothedirectphysiologicaleffectsofasubstance(e.g.,adrugofabuse,amedication)orageneralmedicalcondition(e.g.,hypothyroidism)ThesymptomsarenotbetteraccountedforbyBereavement,i.e.,afterthelossofalovedone,thesymptomspersistforlongerthan2monthsorarecharacterizedbymarkedfunctionalimpairment,morbidpreoccupationwithworthlessness,suicidalideation,psychoticsymptoms,orpsychomotorretardation.MD…diagnosisintherealworldDepressedmoodplus….SsleepdisturbanceIlossofinterestorpleasure(anhedonia)GfeelingsofguiltorworthlessnessElowenergyCpoorconcentrationormemoryAappetitedisturbancePpsychomotoragitationorretardationSsuicidalideationREMEMBERTHATDSMCRITERIAAREHELPFULGUIDELINES…..BUTWEALLHAVEALITTLE(ORALOT)INEACHOFUS!!!REVIEWOFCOMMONDISORDERSSCHIZOPHRENIAAFFECTIVEDISORDERSANXIETYDISORDERS(includingPTSD)PERSONALITYDISORDERSATTENTIONDEFICITHYPERACTIVITYEATINGDISORDERSSUBSTANCERELATEDDISORDERSSCHIZOPHRENIAComplexillness,characterizedbyhallucinations,delusions,behavioraldisturbances,disruptedsocialfunctioning,disorganizedspeechand‘negativesymptoms’0.5-1%PrevalenceViolentactsnomorefrequentthanthegeneralpopulationReducedlifeexpectancy,40%attemptsuicide,10-20%succeedTreatmentantipsychoticmedicationsAFFECTIVEDISORDERS~MOODDISORDERSDEPRESSION:common,oftenmissed,nothardtodiagnosewhenyoulookforit,oftensevere,oftenrecurrent,costlyandhighlytreatableBIPOLARDISORDERS~DepressionwithepisodesofelevatedmoodBIPOLARI=withatleastonemanicepisodeBIPOLARII=withhypomanicepisodesAffectiveDisordersDIAGNOSISCRITERIAMDDSevereSx,>5Sx,>2WksDYSTHYMIALesssevere,morepersistentBIPOLARIManiaandDepressionBIPOLARIIHypomania,Depression?CYCLOTHYMIALesssevere,morepersistentSUBSTANCE-INDUCEDConsequenceofUseorw/dANXIETYDISORDERSGENERALIZEDANXIETYDISORDERSOCIALPHOBIASIMPLEPHOBIASPANICDISORDERAGORAPHOBIAPTSDPERSONALITYDISORDERSCLUSTERDESCRIPTIONDISORDERSAOdd/EccentricParanoid/Schizoid/SchizotypalBDramatic/ErraticAntisocial/Borderline/Histrionic/NarcissisticCAnxious/FearfulAvoidant/Dependent/Obsessive-CompulsiveADHDInattention,hyperactivity,impulsivityADHDdoesassociatewithhigherriskforSUDs,butthismaybelimitedtothosewithcoexistingconductorbipolardisorderTreatingADHDwithstimulantsactuallyappearstobeassociatedwithadecreasedriskofdevelopingasubsequentSUDEATINGDISORDERSANOREXIA:oftenseverelyrestrictcaloricintakeorexcessivelyexercise,areunderweightBULEMIA:oftenalternateeatingwithstarvationorpurging,areusuallynormalweightBothgroupsmayabuseappetitesuppressants,diureticsorlaxativesBULEMICSappeartobeatriskforSUDsOnestudyfoundANOREXICStobeatlowerriskforSUDsSUBSTANCEINDUCEDDISORDERSThesedisordersmimicotherpsychiatricdisorders,buttheyareinfactcaused,directlyorindirectly,byuseofsubstancesThisisatremendoussourceofmisdiagnosis,andresultsinineffectivetreatmentofthesubstancedisorderWeliveinasocietywhereitismoresociallyacceptabletobementallyillthanchemicallydependentDiagnosesAssociatedwithClassofSubstances…..DSM-IV-TRDependAbuseIntoxW/DAlcohol++++Amphetamines++++Cannabis+++Cocaine++++Opioids++++Sedatives++++SubstanceInducedMentalDisordersOrganicBrainSyndromesSIDeliriumSIPersistingDementiaSIAmnesticDisorderMimicAxisIDisordersSIPsychoticDisorderSIMoodDisorderSIAnxietyDisorderHallucinogenPersistingPerceptualDisorderSISexualDysfunctionSISleepDisorderASSOCIATIONOFMENTALDISORDERSWITHSUDs

SUDsinclude

ADDICTION:atreatabledisease

ABUSE:apreventablebehavior2003NationalSurveyofDrugUseandHealth(NSDUH)21.3%ofAdultswithSeriousMentalIllness(SMI)hadaSubstanceUseDisorder(SUD)7.9%ofAdultswithoutSMIhadaSUDNicotineandMentalIllness

Grant,B.F.etal,200412MONTHPREVALENCEODDSRATIOMOODDISORDER21%3.3ANXIETYDISORDER22%2.7PERSONALITYDISORDER32%3.3SeriousMentalIllnessandItsCo-OccurrencewithSubstanceUseDisorders,2002Epstein,Barker,VorburgerandMurtha,2004 SAMHSA.GOV17.5millionAdultswithSMI(SeriousMentalIllness)8.3%ofpopulation18-25yo13.2%26-49yo9.5%>50yo4.9%Female10.5%Male6.0%>1race13.6%NatAm12.5%28.9%usedillicitdrug/yrIllicitdrug/yr17.1%Nodrug/yr6.9%SMIdidnotvarybypastyearalcoholuse‘Heavy〞alcohol/mo11.1%vs.8.1%Co-OccurrenceofSMI&SUD33.2millionSMIorSUD13.4million(40.4%)SMI15.5million(47.4%)SUD4.0million(12.2%)SMI+SUDBothDisorders:23.2%ofSMI20.4%ofSUD

RatesofSMI…….WithoutanySUD7.0%AlcoholDependenceorAbuse19.0%IllicitDrugDependenceorAbuse29.1%AlcoholandDrugUseDisorder30.1%LifetimeSUDAmongPersonswithMentalDisorders….Regieretal,1990MENTALDISORDERLIFETIMEPREVLIFETIME