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Integrating: 12-Step Spirituality, 21 st Century Psychopharmacology, Addiction Psychiatry, and Dual Diagnosis Concepts In Addiction Treatment Settings By GARRETT O’CONNOR, M.D . The Radisson-Miyako Hotel San Francisco October 8-11, 2003. ADDICTION MEDICINE: STATE OF THE ART 2003.

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Integrating:

12-Step Spirituality,

21st Century Psychopharmacology,

Addiction Psychiatry,

and

Dual Diagnosis Concepts

In Addiction Treatment Settings

By

GARRETT O’CONNOR, M.D.

The Radisson-Miyako Hotel

San Francisco

October 8-11, 2003

ADDICTION MEDICINE:

STATE OF THE ART 2003


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ADDICTION

IS A

BRAIN

DISEASE


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THE

RE-ENTRY

OF PSYCHIATRY

INTO THE

ADDICTION

TREATMENT FIELD


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ADDICTION IS A

CUNNING

POWERFUL

BAFFLING

DANGEROUS

DEVIOUS

UGLY

&

HIDDEN

DISEASE


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BUT

MORE THAN

A

DISEASE,

ADDICTION IS

A

WAY OF LIFE


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RECOVERY

IS

ALSO

A

WAY

OF LIFE


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ADDICTIONISTHE GREAT IMITATOROFALL DISEASES(Especially Psychiatric Ones)


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INTOXICATION CAN MIMIC OR OBSCURE:

Panic Disorder

Anxiety Disorder

Major Depression

Psychotic Disorder

Bipolar Disorder

Drug-Induced Organic State

Obsessive Compulsive Disorder

Chronic Alcohol/Drug Use

Attention Deficit Disorder


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The Co-occurrence of a

Substance Use Disorder

and a

Psychiatric Disorder

(Major Mental Illness

Or Severe Personality Disorder

In the same Person)

DUAL DIAGNOSIS


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Is Important Because of:

Its Arguably High Prevalence,

(b) Its Prognostic Significance

(c) The Important Rx. Implications of Making a Correct Diagnosis

DUAL DIAGNOSIS


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THE

DIFFERENTIAL

DIAGNOSIS

BETWEEN

CO-OCCURRING

PSYCHIATRIC

DISORDERS

AND

ADDICTIVE DISEASE

IS A

VITAL CLINICAL

DETERMINATION!


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DANGER!

Prescribing Psychotropic Medications for the Wrong Diagnosis

Failure to Prescribe PsychotropicMedications for the Right Diagnosis


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A MISTAKE

EITHER WAY

CAN LEAD TO

EVENTUAL RELAPSE

AND EVEN

DEATH!


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INTEGRATING

TWO POTENTIALLY

ANTI-THETICAL MODELS

“12-STEP” (BPSS)

ABSTINENCE, SPIRITUALITY

SERVICE,

HIGHER POWER,

BIG BOOK AUTHORITY,

GROUP CONSCIENCE.

“PSYCHIATRIC”

DUAL DIAGNOSIS,

MEDICAL AUTHORITY,

PRESCRIPTION AUTHORITY,

PSYCHOTHERAPY,

PSYCHIATRY AS HIGHER POWER.


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I2-STEP ORIENTED

TREATMENT PROGRAMS MUST

NOT

ALLOW

BIOLOGICAL

PSYCHIATRY,

SCIENCE,

AND

PSYCHOTROPIC MEDICATIONS TO

BECOME THEIR

HIGHER POWER


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A

BALANCED

APPROACH

IS

ESSENTIAL


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IT’S

REALLY

AN

ORGANIZATIONAL

CULTURE

PROBLEM!


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Shared beliefs and values of a group: The beliefs, customs, practices, and social behavior of a particular nation, class or group of people.

CULTURE:


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INTEGRATING practices, and social behavior of a particular nation, class or group of people.FIVE CULTURESACTIVE ADDICTIONABSTINENCE-BASEDTREATMENTAND12-STEP SPIRITUALRECOVERYCOGNITIVE-BEHAVIORALTREATMENTDYNAMIC PSYCHIATRY BRAIN RESEARCH &BIOLOGICAL PSYCHIATRY


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EACH ONE practices, and social behavior of a particular nation, class or group of people.

OF

THESE FIVE CULTURES

HOLDS DIFFERENT, AND OFTEN CONFLICTING, BELIEFS ABOUT THE NATURE OF ADDICTION, AND HOW IT SHOULD BE TREATED


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THEREFORE, practices, and social behavior of a particular nation, class or group of people.

THE NATURE, TASK, ROLE,

BOUNDARIES,

AND AUTHORITY

OF EACH CULTURE

MUST BE DEFINED,

UNDERSTOOD,

AND ACCEPTED


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FOR EXAMPLE, practices, and social behavior of a particular nation, class or group of people.

DIFFERENTIATE

TREATMENT

FROM

RECOVERY!


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DIFFERENTIATE practices, and social behavior of a particular nation, class or group of people.

ABSTINENCE

FROM

HARM REDUCTION

FROM

CONTROLLED

DRINKING


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SOME practices, and social behavior of a particular nation, class or group of people.

“DIFFICULT”

ELEMENTS

OF

12-STEP

SPIRITUALITY


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THE practices, and social behavior of a particular nation, class or group of people.

SPIRITUAL CONCEPT

OF A

HIGHER POWER


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ACCEPTANCE practices, and social behavior of a particular nation, class or group of people.

AND

SURRENDER


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THE practices, and social behavior of a particular nation, class or group of people.

INFLATED

ALCOHOLIC

EGO

MUST BE

DEFLATED

AT DEPTH

(Bill W.)


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SELECT practices, and social behavior of a particular nation, class or group of people.

AND

SUBMIT

TO A

SPONSOR


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SERVICE IN AA practices, and social behavior of a particular nation, class or group of people.

COMMITMENTS

12-STEP WORK

WORK WITH

NEWCOMERS

H & I

G.S. REPRESENTATIVE

SPONSORSHIP

CENTRAL OFFICE


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SOBRIETY practices, and social behavior of a particular nation, class or group of people.

IS AN

UNNATURAL

STATE

FOR

ADDICTS


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SOBRIETY practices, and social behavior of a particular nation, class or group of people.

IS

THE

#1

CAUSE

OF RELAPSE


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  • GIFTS FOR RECOVERING ALCOHOLICS practices, and social behavior of a particular nation, class or group of people.

  • (Opportunities for Spiritual Growth)

  • Suffering!

  • Humiliation!

  • Disappointment!

  • Disillusionment!

  • Betrayal!

  • Loss!

  • Extreme Guilt & Shame!

  • Abandonment!

  • Failure!

  • Success!


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THE practices, and social behavior of a particular nation, class or group of people.

SPIRITUAL

VALUE

OF

SUFFERING


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THE practices, and social behavior of a particular nation, class or group of people.

RE-ENTRY

OF PSYCHIATRY

INTO THE

ADDICTION

TREATMENT FIELD


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ABOUT practices, and social behavior of a particular nation, class or group of people.

50%

OF ALCOHOLIC/ADDICTS ADMITTED

TO

THE BETTY FORD CENTER

ARE ALREADY ON PSYCHOTROPIC

MEDICATIONS PRESCRIBED BY PCP’S

OR PSYCHIATRISTS, OFTEN WITHIN 3-6 MONTHS PRIOR TO ADMISSION


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  • SCIENTIFIC EVIDENCE FOR ADDICTION AS A BRAIN DISEASE practices, and social behavior of a particular nation, class or group of people.

  • NEW EMPHASIS ON THE

  • DUAL DIAGNOSIS CONCEPT

  • AGGRESSIVE TV AND OTHER MASS MARKETING OF SSRI AND OTHER PSYCHOTROPIC DRUGS; BENZO’S ETC.

  • AWARENESS OF POPULATIONS NEEDING TREATMENT. E.G., LICENSED PROFESSIONALS,

  • URBAN HOMELESS ETC.


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PSYCHIATRY practices, and social behavior of a particular nation, class or group of people.

AND PHARMACEUTICAL COMPANIES

BELIEVED THEY COULD ENHANCE THE EFFECTIVENESS OF

12-STEP

TREATMENT & RECOVERY

FROM LATE 80’S,

MAJOR ADDICTION MEDICINE SOCIETIES

(AAPA; ASAM; CSAM; Etc.)

ACCEPTED “EDUCATIONAL”

MONIES FROM DRUG COMPANIES


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DRAMATIC practices, and social behavior of a particular nation, class or group of people.

BREAKTHROUGHS!

NEW FRONTIERS!

REVOLUTIONARY ADVANCES!

EVIDENCE-BASED

TREATMENT APPROACHES


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Disulfiram practices, and social behavior of a particular nation, class or group of people.

Naltrexone

LAAM

Acamprosate

Methadone

Buprenorphine

Mood Regulators

Anti-depressants

Sedative-hypnotics (Rarely, if ever)

Anti-psychotics (When indicated)

DRUGS USED AFTER DETOXIFICATION INTREATMENT OF ADDICTION


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  • DUAL DIAGNOSIS practices, and social behavior of a particular nation, class or group of people.

  • PSYCHOTROPIC

  • MEDICATIONS

  • IN RECOVERY

  • BOO-HOO FOR 12-STEP!

  • (NO “SCIENTIFIC” EVIDENCE!)


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ON THE CONTRARY, practices, and social behavior of a particular nation, class or group of people.

RECENT RESULTS

FROM

PROJECT MATCH

SUGGEST THAT

AA

MAY BE THE MOST EFFECTIVE

APPROACH

FOR

LONG-TERM

ABSTINENCE

AND

SOBRIETY


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POTENTIALLY practices, and social behavior of a particular nation, class or group of people.

USEFUL & VALID

NEW

TECHNOLOGIES

MAY BE EXPERIENCED

BY STAFF AS

THREATS

TO THE

12-STEP CULTURE


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AFTER DETOXIFICATION, practices, and social behavior of a particular nation, class or group of people.

PSYCHOTROPIC

MEDICATIONS SHOULD

BE

PRESCRIBED

FOR ALCOHOLICS AND OTHER ADDICTS

IN RECOVERY

ONLY WHEN THE DIAGNOSIS

OF DUAL DISORDER

HAS

BEEN

CONFIRMED


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INSENSITIVE practices, and social behavior of a particular nation, class or group of people.

DANGEROUS (ANTI-AA)

ARROGANT

DRUG-ORIENTED

IGNORANT ABOUT ADDICTION

ABUSIVE

NON-SPIRITUAL

MINIMIZE IMPACT OF ALCOHOL

MONEY-GRUBBING

COMPETITIVE

CONTEMPTUOUS

THREATENING

NEGATIVE ATTITUDES IN AAABOUT PSYCHIATRISTS/PSYCHOTHERAPY


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SUBSTITUTE DEPENDENCY practices, and social behavior of a particular nation, class or group of people.

AA IS “ADJUNCTIVE”

A FOLK MOVEMENT

RELIGIOUS BIBLE THUMPING

A CULT

FOSTERS DEPENDENCY IN MEMBERS

NO FOLLOW-UP

NO CONTROLLED RESEARCH

EFFICACY NOT PROVED

DISORGANIZED

HOSTILE TO PSYCHIATRY

LACKSACCOUNTABILITY

UNCOOPERATIVE

COMPETITIVE

NON-INTELLECTUAL

FREE

NEGATIVE ATTITUDES OF PSYCHIATRY TOWARDS AA


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GRATITUDE practices, and social behavior of a particular nation, class or group of people.

(38% OF AA MEMBERS SAY THEY WERE REFERRED TO THE PROGRAM BY PSYCHIATRISTS OR OTHER THERAPISTS)

MANY AA MEMBERS EXPRESS GRATITUDE TO PSYCHIATRISTS FOR SUPPORT AND FOR PRESCRIPTIONS OF ANTI-DEPRESSANTS OR SSRI’S WHICH THEY SAY “GOT THEM THROUGH”,“TOOK THE EDGE OFF”, OR “MADE IT POSSIBLE FOR THEM TO STAY SOBER”.

POSITIVE ATTITUDES IN AAABOUT PSYCHIATRISTS, PSYCHOTHERAPYAND COUNSELORS


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SUPPORTIVE practices, and social behavior of a particular nation, class or group of people.

LIFE-SAVING

INDISPENSABLE

DIVINELY INSPIRED

COOPERATIVE

COMPLEMENTARY

REVOLUTIONARY

ADMIRATION

GRATITUDE

POSITIVE ATTITUDES IN PSYCHIATRY ABOUT AA


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NEGATIVE 12-STEP ATTITUDES TOWARD MEDICATIONS practices, and social behavior of a particular nation, class or group of people.

A Crutch

Easier Softer Way

Impede Spiritual Recovery

Foster Dependency

Substitute for Higher Power

Violate AA Traditions

Bad Example for Newcomers

Ill-Trained Physicians

Stupid Physicians

Criminal Conduct by Docs


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  • UNDERSTANDING RECOVERY practices, and social behavior of a particular nation, class or group of people.

  • AND ADDICTION (M.BEAN)

  • THE NATURE OF ADDICTION

  • THE THINKING DISORDER

  • (“STINKIN THINKIN”)

  • THE MECHANICS & DYNAMICS

  • OF RECOVERY

  • THE ALCOHOLIC IDENTITY

  • THE RECOVERING IDENTITY

  • THE ROLE OF SPIRITUALITY IN RECOVERY

  • AA IS NOT “AN ADJUNCT” TO

  • PSYCHOTHERAPY


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SHAME practices, and social behavior of a particular nation, class or group of people.


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PERSONAL, practices, and social behavior of a particular nation, class or group of people.

PROFESSIONAL,

AND

MEDICAL

SHAME


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PRINCIPLES FOR INTEGRATING practices, and social behavior of a particular nation, class or group of people.

12-STEP AND DUAL DIAGNOSIS PROGRAMS

Needs Assessment

Establish Vision & Mission

Survey Staff Attitudes

Create Policies and Procedures

Educate Referents

Adequate Staff Education

Cross-Training for Staff

Capability for Longer Stay

Double Trudger’s Groups

Integrated or Segregated Treatment Tracks?

Expert Differential Diagnosis

Drug-free Observation Period

13. Experienced Medical and Psychiatric Direction


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CRF practices, and social behavior of a particular nation, class or group of people.

ANTAGONISTS

MAY

INTERRUPT STRESS CYCLES,

BLOCK DOMINO

EFFECTS,

AND

PREVENT

BIOLOGICAL CASCADING

INTO

DEEPER LEVELS

OF

STRESS


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IN THE MEANTIME, practices, and social behavior of a particular nation, class or group of people.

EVERY ONE HOPES

THAT

SOMETHIHG

ALREADY OUT THERE

(a drug, that is)

WILL

BE FOUND

TO BE

EFFECTIVE!


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URGENT practices, and social behavior of a particular nation, class or group of people.

NEED

TO FORMALLY

ADDRESS THESE

CULTURAL DIFFERENCES WITHIN THE

FIELD TO

FACILITATE

BENCH TO BED

TO COMMUNITY

TRANSLATIONAL

INITIATIVES


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THE SERENITY PRAYER practices, and social behavior of a particular nation, class or group of people.

God grant me the serenity to accept the things I cannot change

The courage to change the things I can

And the wisdom to know the difference