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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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slide1
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

slide2

ADDICTION

IS A

BRAIN

DISEASE

slide3

THE

RE-ENTRY

OF PSYCHIATRY

INTO THE

ADDICTION

TREATMENT FIELD

slide4

ADDICTION IS A

CUNNING

POWERFUL

BAFFLING

DANGEROUS

DEVIOUS

UGLY

&

HIDDEN

DISEASE

slide5
BUT

MORE THAN

A

DISEASE,

ADDICTION IS

A

WAY OF LIFE

slide6
RECOVERY

IS

ALSO

A

WAY

OF LIFE

slide8
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

dual diagnosis
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
dual diagnosis10
Is Important Because of:

Its Arguably High Prevalence,

(b) Its Prognostic Significance

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

DUAL DIAGNOSIS
slide11
THE

DIFFERENTIAL

DIAGNOSIS

BETWEEN

CO-OCCURRING

PSYCHIATRIC

DISORDERS

AND

ADDICTIVE DISEASE

IS A

VITAL CLINICAL

DETERMINATION!

slide12
DANGER!

Prescribing Psychotropic Medications for the Wrong Diagnosis

Failure to Prescribe PsychotropicMedications for the Right Diagnosis

slide13
A MISTAKE

EITHER WAY

CAN LEAD TO

EVENTUAL RELAPSE

AND EVEN

DEATH!

slide14
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.

slide15

I2-STEP ORIENTED

TREATMENT PROGRAMS MUST

NOT

ALLOW

BIOLOGICAL

PSYCHIATRY,

SCIENCE,

AND

PSYCHOTROPIC MEDICATIONS TO

BECOME THEIR

HIGHER POWER

slide16

A

BALANCED

APPROACH

IS

ESSENTIAL

slide17

IT’S

REALLY

AN

ORGANIZATIONAL

CULTURE

PROBLEM!

culture
Shared beliefs and values of a group: The beliefs, customs, practices, and social behavior of a particular nation, class or group of people.CULTURE:
slide19

INTEGRATINGFIVE CULTURESACTIVE ADDICTIONABSTINENCE-BASEDTREATMENTAND12-STEP SPIRITUALRECOVERYCOGNITIVE-BEHAVIORALTREATMENTDYNAMIC PSYCHIATRY BRAIN RESEARCH &BIOLOGICAL PSYCHIATRY

slide20

EACH ONE

OF

THESE FIVE CULTURES

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

slide21

THEREFORE,

THE NATURE, TASK, ROLE,

BOUNDARIES,

AND AUTHORITY

OF EACH CULTURE

MUST BE DEFINED,

UNDERSTOOD,

AND ACCEPTED

slide22

FOR EXAMPLE,

DIFFERENTIATE

TREATMENT

FROM

RECOVERY!

slide23

DIFFERENTIATE

ABSTINENCE

FROM

HARM REDUCTION

FROM

CONTROLLED

DRINKING

slide24
SOME

“DIFFICULT”

ELEMENTS

OF

12-STEP

SPIRITUALITY

slide25
THE

SPIRITUAL CONCEPT

OF A

HIGHER POWER

slide26
ACCEPTANCE

AND

SURRENDER

slide27
THE

INFLATED

ALCOHOLIC

EGO

MUST BE

DEFLATED

AT DEPTH

(Bill W.)

slide28
SELECT

AND

SUBMIT

TO A

SPONSOR

slide29

SERVICE IN AA

COMMITMENTS

12-STEP WORK

WORK WITH

NEWCOMERS

H & I

G.S. REPRESENTATIVE

SPONSORSHIP

CENTRAL OFFICE

slide30

SOBRIETY

IS AN

UNNATURAL

STATE

FOR

ADDICTS

slide31

SOBRIETY

IS

THE

#1

CAUSE

OF RELAPSE

slide32

GIFTS FOR RECOVERING ALCOHOLICS

  • (Opportunities for Spiritual Growth)
  • Suffering!
  • Humiliation!
  • Disappointment!
  • Disillusionment!
  • Betrayal!
  • Loss!
  • Extreme Guilt & Shame!
  • Abandonment!
  • Failure!
  • Success!
slide33

THE

SPIRITUAL

VALUE

OF

SUFFERING

slide35

THE

RE-ENTRY

OF PSYCHIATRY

INTO THE

ADDICTION

TREATMENT FIELD

slide36

ABOUT

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

slide37

SCIENTIFIC EVIDENCE FOR ADDICTION AS A BRAIN DISEASE

  • 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.
slide38
PSYCHIATRY

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

slide39
DRAMATIC

BREAKTHROUGHS!

NEW FRONTIERS!

REVOLUTIONARY ADVANCES!

EVIDENCE-BASED

TREATMENT APPROACHES

drugs used after detoxification in treatment of addiction
Disulfiram

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
slide41

DUAL DIAGNOSIS

  • PSYCHOTROPIC
  • MEDICATIONS
  • IN RECOVERY
  • BOO-HOO FOR 12-STEP!
  • (NO “SCIENTIFIC” EVIDENCE!)
slide42

ON THE CONTRARY,

RECENT RESULTS

FROM

PROJECT MATCH

SUGGEST THAT

AA

MAY BE THE MOST EFFECTIVE

APPROACH

FOR

LONG-TERM

ABSTINENCE

AND

SOBRIETY

slide43
POTENTIALLY

USEFUL & VALID

NEW

TECHNOLOGIES

MAY BE EXPERIENCED

BY STAFF AS

THREATS

TO THE

12-STEP CULTURE

slide44

AFTER DETOXIFICATION,

PSYCHOTROPIC

MEDICATIONS SHOULD

BE

PRESCRIBED

FOR ALCOHOLICS AND OTHER ADDICTS

IN RECOVERY

ONLY WHEN THE DIAGNOSIS

OF DUAL DISORDER

HAS

BEEN

CONFIRMED

negative attitudes in aa about psychiatrists psychotherapy
INSENSITIVE

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
negative attitudes of psychiatry towards aa
SUBSTITUTE DEPENDENCY

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
positive attitudes in aa about psychiatrists psychotherapy and counselors
GRATITUDE

(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
positive attitudes in psychiatry about aa
SUPPORTIVE

LIFE-SAVING

INDISPENSABLE

DIVINELY INSPIRED

COOPERATIVE

COMPLEMENTARY

REVOLUTIONARY

ADMIRATION

GRATITUDE

POSITIVE ATTITUDES IN PSYCHIATRY ABOUT AA
slide49
NEGATIVE 12-STEP ATTITUDES TOWARD MEDICATIONS

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

slide50

UNDERSTANDING RECOVERY

  • 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
slide52

PERSONAL,

PROFESSIONAL,

AND

MEDICAL

SHAME

slide53
PRINCIPLES FOR INTEGRATING

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

slide54

CRF

ANTAGONISTS

MAY

INTERRUPT STRESS CYCLES,

BLOCK DOMINO

EFFECTS,

AND

PREVENT

BIOLOGICAL CASCADING

INTO

DEEPER LEVELS

OF

STRESS

slide55

IN THE MEANTIME,

EVERY ONE HOPES

THAT

SOMETHIHG

ALREADY OUT THERE

(a drug, that is)

WILL

BE FOUND

TO BE

EFFECTIVE!

slide56

URGENT

NEED

TO FORMALLY

ADDRESS THESE

CULTURAL DIFFERENCES WITHIN THE

FIELD TO

FACILITATE

BENCH TO BED

TO COMMUNITY

TRANSLATIONAL

INITIATIVES

slide57

THE SERENITY PRAYER

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