December 10 - PowerPoint Presentation

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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

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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