gp addicition management
Post on 23-Jan-2018
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zelko.mustac@gmail.com
Music Royalty free www.benesound.com
DR Zelko Mustac
Psychiatrist
Your URL or Logo (on every slide)
For detailed information on these slides
What are we going to
learn? (and why it’s
important to learn now).The best case is that you replace these words with pictures. But to brainstorm, bullet points
aren’t a bad place to start. Also you can experiment with using presentation notes (but those
keep you at the podium.)
What are we going to learn?
The problem
For Patient who have repeatedly tried but failed to achieve sobriety.
Legislators have foreseen this situation and provided for it (for
France [13]). Off-label prescribing is permitted under the
following conditions:
- Scientific data justify this therapeutic use. - It is required as
a treatment due to the failure of properly conducted
conventional therapies. - The patient has been given
comprehensive information concerning the potential benefits
and risks of the treatment. - Informed consent of the patient
and his written acceptance to take this treatment with full
knowledge of the risks involved. - Appropriate medical
monitoring. -
The before and after
Ameisen.
• Disulfiram (Antabuse) since 1970’s
• Acomprosate (Campral) - limited
• Naltrexone (? 30%)
• Nalmefene (not in Oz)
• Topirimate (2nd line)
• SSRI’s/Ondansetron
• Psychosocial
“The End Of My Addiction “Olivier
Ameisen
• “In the depths of a desperate struggle with
alcoholism, I found a medicine, baclofen,
that both freed me of all craving for alcohol
and resolved the underlying disorder,
overwhelming anxiety, that made me
vulnerable to addiction.”
• RPHx Emergency Physican
Before solution 1.
• 35 yr old White Australian woman
• Caring successful parents
• Failing 2nd Marriage
• All treatments have been tried and failed
• Unhappy re: “controlling spouse”
After solution 1 .
• She stopped drinking entirely
• Now working in Aged Care “loving it”
• Marital Problems no longer an issue
• No further treatment in 4 years
Before solution 2.• Retired (64yr old) successful executive.
• Falling through glass windows,
• Wife attempting to “dole out EtOH”
• Repeated serious falls and injuries
After solution .• Previously 2 admissions without sobriety
• Now drinks 1-2 Standard drinks/day
• Wife wants him in Antabuse
Before solution 3.• Pretty 32 yr old UK immigrant
• Binge drinker from age of 18
• Hb FIFO, binges when he leaves
• Marriage about to end.
• No Health Insurance to detoxify
After solution (story or
case study) #3.
• Became nominated driver at Hen’s nights
• No hospital admission required
• Moved to N.W. for Hb’s work
• No psychological treatment.
Stages of Change
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Termination
Rational Emotive Therapy (CBT)
• Cognitive Restructuring- Anger, Self-Blame, Self-Pity, Other-
Pity, Demandiness
• Defects• Rigidity
• USA
• UOA
• Specific Stimuli leads to Urges (Thoughts create
Feelings)
• Observer Status (Instead of Victim Status)
Skills Training
• Self- Soothing, Mindfulness (Headspace), Self acceptance, Other
Acceptance
• Habit Model – Takes 3 months to change a habit, Prefrontal Cortex
Automated functioning, Addictions are a habit
• Environmental Cues – To change a habit, Pictures, Audio
recordings, House Clean, Friend, phone Clean
• New Habits, Family, Friends, Work, Finances
• Ongoing Support, Failure is when you stop trying
• Cognitive Function Assessment
Assessment
• Has drinking resulted in employment, legal,
family, friendship problems ?
• Do you have memory, mood or irritability
problems related to your drinking
• EtOh impairs recollection, under-reporting is
common
• Drink to get going? (10% lifetime preval.)
• Understate the patient’s concerns
Depression and Alcohol Use
• Over 70% Depressed in 1st week of sobriety
• Less than 10% by 3rd week
• Suicidality, Depression preceding EtOh Use,
Pessimism, Family History
• Prognosis is better if EtOh Use driven by
Depression and Depression is treated with
SSRI
• SSRI ineffective in non- depressed EtOh
Psychiatric Comorbidity
• Bipolar Disorder 5X
• PTSD, Depression 2X
• Early Childhood Trauma – lack of effective
Reward Pathways, lack of self-soothing
• Remember “HALT” and Craving
Motivational Interviewing
• Ask Leading Questions
• Establish what the patient (customer) wants
from seeing you
• Request permission to offer interventions
now or in the future
• Don’t get ahead of where the patient
(customer) is.
• Time is rarely a factor (time poor treatment)
Psychological Treatments
• Project Match – 3 treatments
• Motivational Interviewing
• Contingency Management, Cognitively Impaired
• 12 Step Programme ( AA, Smart Recovery)• Social Support key to Group Therapy
The mistakes people
make.• No chemical solution?
• I want patient to change !
• Change can be totally unexpected !
• Baclofen won’t work every time, have a
backup plan !
What you can do to take
action now.• Check for Hypertension/Diabetes.
EtOh
• Develop Motivational Interviewing
• Try Baclofen (Anxiety not required)
• Increase the dosage to side-effect
level
• Then 2nd Tier Craving reduction agent
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