2015 Arthur Robin Williams MD MBE American Academy of Addiction Psychiatry Division on Substance Abuse Department of Psychiatry Columbia University New York State Psychiatric Institute Clinical ID: 606350
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December 10, 2015Arthur Robin Williams MD MBEAmerican Academy of Addiction PsychiatryDivision on Substance AbuseDepartment of Psychiatry, Columbia UniversityNew York State Psychiatric Institute
Clinical Management: Alcohol Use DisordersSlide2
NIAAA website has many resourceshttp://rethinkingdrinking.niaaa.nih.gov/ Free 16-page bookletshttp://pubs.niaaa.nih.gov/publications/RethinkingDrinking/OrderPage.htm Slide3
AUD Treatment OptionsLevel of Care:- Outpatient - Individual - Program- Residential- Inpatient/ HospitalSlide4
AUD Treatment OptionsLevel of Care:- Outpatient - Individual - Program- Residential- Inpatient/ Hospital
- Detoxification- Aversion- Anti-Craving- SubstitutionSlide5
11 Symptoms of AddictionSlide6
Addiction & Problematic Use
Addiction:
chronic disease
needs treatment
Up to
16%
of the 12+
population
Problematic use:
Substance use that threatens health & safety
Does not meet addiction criteria
Up to
32%
of the 12+ population
Both require medical care
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Addiction & Problematic Use
SBIRT
:
S
creening,
B
rief
I
ntervention,
R
eferral to
T
reatment
All
patients diagnosed with
addiction
should receive
treatment
All patients with
problematic use
should receive a
brief intervention
7Slide8
NeuropathologyAnti-glutaminergicPotentiates GABADopamine releaseAlcoholSlide9
Targeting SymptomsMedications (MAT)
- Detox taper(Librium orMethadone)Slide10
MAT: AlcoholDetoxification (Youth typically binge drink and rarely require)Use benzodiazepines, phenobarbitalOutpatient v. inpatient modelsAversionAntabuse 250mg or 500mg daily (FDA 1951) Start after all alcohol has clearedCan dose on site or have observer at homeEffects for up to 2-3 weeks for someConsider as an adjunct to psychosocial
therapiesMonitor liver function every 1-3 monthsSlide11
Targeting SymptomsMedications (MAT)
Aversion (Antabuse)- Anti-Craving(Naltrexone)Slide12
MAT: AlcoholAnti-CravingCampral 666mg TID (FDA 2004) Stabilizes neuroexcitability in protracted withdrawalDosing is problematic (but no side effects)Better choice for patients with liver diseaseNaltrexone 50mg daily (NTX) (FDA 1994) Reduces number of drinks per drinking day and cravingsSide effects limited (nausea/sedation)LFTs should be followed intermittently (every 3 months)
Vivitrol 380mg IM (XR-NTX) (FDA 2006) Long acting monthly injection of naltrexoneSlide13
MAT includesAntabuse (disulfiram) 250mg or 500mg dailyNaltrexone 50mg+ daily or monthly Vivitrol injectionAcamprosate 666mg PO TIDDosing should be observed by family or programCheck liver function regularly if on naltrexone or AntabuseSummary: AlcoholSlide14
If pill taking not witnessed, assume not takenPatients often “fail” naltrexone on path to antabuseRoll with resistance if patients attempt “moderation”SMART Recovery is an alternative to AA/NATreating anxiety and sleep is key in first few monthsCBT, behavioral treatment: www.cbtforinsomnia.comSedating anti-depressants, gabapentin, etc.Clinical Tips: AlcoholSlide15
CBT for Insomnia: http://www.med.upenn.edu/cbti/Niederhofer, H. and W. Staffen (2003). "Acamprosate and its efficacy in treating alcohol dependent adolescents." Eur Child Adolesc Psychiatry 12(3): 144-148.Niederhofer, H. and W. Staffen (2003). "Comparison of disulfiram and placebo in treatment of alcohol dependence of adolescents." Drug Alcohol Rev 22(3): 295-297.Simkin, D. R. and S. Grenoble (2010). "Pharmacotherapies for adolescent substance use disorders." Child Adolesc Psychiatr Clin N Am
19(3): 591-608.References