Management of the Addicted Patient in Primary Care Management of the Addicted Patient in Primary Care Heidi Allespach Pomm, PhD Faculty and Coordinator of Behavioral Science, Family Medicine Residency Program, St. Vincent’s Medical Center, Jacksonville, Florida; Clinical Associate Professor, College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, Florida; Voluntary Faculty, Department of Family Medicine and Community Health, University of Miami Miller School of Medicine, Miami, Florida Raymond M. Pomm, MD Medical Director, Florida Impaired Practitioners Program; Medical Director, River Region Human Services; Medical Director, Gateway Community Services; Expert Consultant to the Florida Board of Bar Examiners in Matters Related to Impairment; Clinical Assistant Professor, Department of Psychiatry, University of Florida, Gainesville, Florida Heidi Allespach Pomm, PhD Faculty and Coordinator of Behavioral Science, Family Medicine Residency Program, St. Vincent’s Medical Center, Jacksonville, Florida; Clinical Associate Professor, College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, Florida; Voluntary Faculty, Department of Family Medicine and Community Health, University of Miami Miller School of Medicine, Miami, Florida Raymond M. Pomm, MD Medical Director, Florida Impaired Practitioners Program; Medical Director, River Region Human Services; Medical Director, Gateway Community Ser- vices; Expert Consultant to the Florida Board of Bar Examiners in Matters Related to Impairment; Clinical Assistant Professor, Department of Psychiatry, University of Florida, Gainesville, Florida In Chapter 2, the Twelve Steps and brief excerpts from the book Alcoholics Anonymous and the Twelve Steps and Twelve Traditions are reprinted with permission of Alcoholics Anonymous World Services, Inc. (AAWS). Permission to reprint a brief excerpt from the book Alcoholics Anonymous and the Twelve Steps does not mean that AAWS has reviewed or approved the contents of this publication or that AAWS necessarily agrees with the views expressed herein. Alcoholics Anonymous (AA) is a program of recovery from alcoholism only—use of the Twelve Steps in connection with programs and activities that are patterned after AA but that address other problems, or in any other non-AA context, does not imply otherwise. All case studies in this book are hypothetical. Names and anecdotes are fi ctional and serve illustrative purposes only. Any similarities to persons living or dead is purely coincidental and unintentional. All drugs discussed by name in this book have specifi c uses approved by the U.S. Food and Drug Administration. The potential for abuse occurs when the manufacturer’s recommendations are not followed. The opinions expressed are those of the Authors and not those of the Publisher. The ultimate responsibility for the use and dosage of drugs mentioned in the book and in the interpretation of published material lies with the medical practitioner, and the Authors and Publisher accept no liabil- ity whatsoever with respect to any claim for damages arising therefrom. Library of Congress Control Number: 2007921868 ISBN: 978-0-387-35961-8 e-ISBN: 978-0-387-71885-9 Printed on acid-free paper. © 2007 Springer Science+Business Media, LLC. All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in con- nection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identifi ed as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. 9 8 7 6 5 4 3 2 1 springer.com I dedicate this book to my father and exemplary psychiatrist, Dr. Bruce Walter Alspach, and to my wonderful mother, Mrs. Maxine Farr Alspach, for their unwavering, unconditional love and support throughout the years. No one could ever ask for better parents than you. I also dedicate this book to my dear and beloved friend, Dianne Gars. Thank you for sharing your “experience, strength, and hope” and for always standing strong beside me during all of these years. I am so grateful you were put into my life, and I love you more than words can ever express. To the millions of recovering alcoholics and addicts who have had the courage to move from the darkness of active disease into the light of sobriety . . . thank you for all you have taught me, and may your lives always be “happy, joyous, and free!” Last but never least, this book is dedicated with a tremendous amount of love and admiration to my “team”; my amazing, smart, beautiful, and incredi- bly big-hearted daughter, Summer; and my wonderful husband and soulmate, Ray. I cherish the love you both give me more than anything in the world, and this book would not have been possible without you. —HP I dedicate this book to my family. First, to my parents, Monty and Eileen, who, beyond raising me, were there in so many ways as I traveled this tortuous journey through life. Their expectations and modeling steered my academic and professional direction. Their support has been consistent and backed by a lifetime of love. My sister, Laureen: whose life’s decisions started me on my journey into the fi eld of psychiatry. Even though she has lived in a foreign country, her presence and unconditional love have always been felt. My son, David, has loved me and, with wisdom beyond his years, under- stood my busy work schedule. His acceptance and respect have been realized at my core, fueling my desire to be the very best I can be for him and for all those around me. My new daughter, Summer, has showered me with a love I would never have experienced. Her presence in my life has brought a new light to help brighten the way. She has shown me a new energy that has strengthened my belief in the future, for both those who are healthy and those who are ill. Last, but certainly not least, my wife, Heidi: my best friend, my life partner, my lover, and my soulmate. She has always been by my side, forever supporting me, even when life seems so overwhelming. Without her, this book would never have been written. She is the love of my life. —RP Foreword Tobacco, alcohol, illicit drugs, and secondhand exposure are the nation’s leading health problems. These acquired problems cause more than half of all deaths per year. First use, as well as some subsequent use, may be voluntary, but after loss of control, continued use is to be expected in an addict. So, prevention is the treatment of choice and also the treatment with the greatest effi cacy. When prevention fails, early intervention and prompt treatment are critical; other- wise, abuse becomes dependence and with it comes a chronic life-long disease without a specifi c cure. This places a great deal of responsibility on the already overburdened primary care physicians, who must identify a disease fraught with denial and whose patients are generally the last ones to know and accept the fact that they are hopelessly addicted and need help. Physician education and competency make early diagnosis more likely, but most practicing physi- cians do not have addiction education or treatment training as part of their undergraduate medical education. Among physicians, tobacco competency has improved, and a smoking history is now a part of almost every new patient assessment. A patient’s attempts to quit and pharmacologic treatments have been incorporated into most practices in which the physician emphasizes well- ness. Most physicians have prescribed and followed patients treated with nico- tine replacement and Zyban. Progress in the treatment of alcohol abuse and dependence, cocaine and prescription misuse and dependence, and other drugs of abuse has been much slower. All drugs of abuse have similar net effects on the brain and cause a sub- stance abuse dependence syndrome that is stereotyped and consistent whether the patient is homeless or a physician. Our group has worked to understand the likely neurobiology of addictions. Our work and the work of others, such as Koob and Volkow, with opioid drugs and the noradrenergic systems, cocaine and the dopamine systems, and tobacco and cannabinoids has been well ref- erenced and summarized where appropriate. Like ourselves, Pomm and Pomm understand that detoxifi cation, whether fast or slower or whether with this medication or that, is rarely a treatment. Detoxifi cation is a fi rst step in the treatment of dependence, but treatment really begins after detox. Although cutting-edge science has a central place in this text, the focus is clearly not on science for science’s sake, but rather on the research that translates to people. It is one thing to point out that the brain has cannabinoid receptors and that they have a certain distribution and evolutionary biology. It is quite another to point out that these systems can be blocked with pharmaceuticals to produce a reduced attraction to substances. The authors do a very good job of explain- ing and anticipating the research progress in anticraving agents for alcohol dependence. As one of the most experienced physicians identifying and studying physi- cian addicts before and after treatment, Dr. Ray Pomm certainly has pioneered viii Foreword the use of drug testing and has identifi ed testing as an important treatment for addicts. Dr. Pomm understands the importance of using drug testing for diagnosis, prevention, and treatment monitoring. When abstinence is the outcome desired, as it is in physician addictions, positive urine tests are critical and useful outcome measures. While easily explaining pharmacologic and nonpharmacologic treatments, abstinence approaches, and the 12 steps, the authors are equally comfortable with the offi ce treatment of opioid addicts with buprenorphine or naltrexone or methadone. It is so refreshing to see treatments presented impartially in an evidenced base-framework of balanc- ing clinical experience, options, and outcomes. The authors also clearly under- stand polydrug use and comorbidity. Both are important in the world today where the majority of current cigarette smokers also have a primary psychiat- ric disease, usually depression or schizophrenia. Being comfortable treating the complete patient is a tall order, but the authors provide helpful advice to make this more likely to happen. Therefore, it is a great pleasure to write this foreword to Ray and Heidi Pomm’s Management of the Addicted Patient in Primary Care. I have known Ray Pomm for more than 25 years as a physician expert in addictive disease. Heidi Pomm is a family practitioner mentor and teacher, clinician, and special- ist in behavioral treatments for addiction. Together, they have spent their careers thinking about the issues that comprise this text. They have crafted a comprehensive, yet primary care physician-friendly textbook. One challenge to anyone who tries to write a textbook for primary care physicians, the front line and ground zero in the challenge of early detection and prompt nonhos- pital treatment, is to balance everything that we know about addiction with everything that the practicing physician needs to know to help the patient in the offi ce. Pomm and Pomm’s text describes the important core knowledge in addiction medicine and provides a “how to” approach to intervention and treatment that was possible for them to achieve by utilizing vast clinical experi- ence. This book is easy to read and as up to date as any text. Their goal is to improve the education of physicians to the point that they are comfortable and competent treating abusers and addicts. This is a critical mission and attain- able if we energize and reemphasize undergraduate and graduate training in addiction medicine as an essential core in compulsory medical education. Mark S. Gold, MD Distinguished Professor and Chief McKnight Brain Institute Departments of Psychiatry, Neuroscience, Anesthesiology, Community Health, and Family Medicine Division of Addiction Medicine Preface Whether you like it or not, it is inevitable. You will be (or are) treating alcohol- ics and addicts who are showing either overt, or covert, symptoms of their disease. In fact, a large number of patients who will seek your help are strug- gling with substance use disorders; yet the medical establishment is still failing in large numbers to diagnose {addictive disease} in their patients. Adults and adolescents with substance use disorders (SUD) are likely to be the most diffi cult patients you will see in your practice. Common physician reactions to these patients include anger, frustration, disgust, and apathy— emotions which may cause the physician to misdiagnose or fail to recognize substance abuse in these patients. In a survey by The National Center on Addiction and Substance Abuse at Columbia University (CASA), it was demonstrated that 94 percent of primary care physicians failed to include substance abuse among the fi ve diagnoses they offered when presented with early symptoms of alcohol abuse in an adult patient. Furthermore, these researchers found that 41 percent of pediatricians failed to diagnose illegal drug use even when presented with a classic descrip- tion of a drug-abusing adolescent patient. Some of the greatest barriers to accurate diagnosis appear to be time constraints and patient dishonesty about use. In addition, skepticism about the success of treatment of addicts among physicians appears to be common. Taken together, it appears that it is more necessary than ever for physicians to have the knowledge and skills to appro- priately address this population (Califano, 1998; Miller & Sheppard, 1999). In an attempt to fi ll some of the knowledge-based defi cits, it is expected that this book will give you the necessary skills to accurately recognize, diagnose and treat your patients with substance use disorders. First and foremost, it is important to remember that, when treating patients with addictive illness, ignorance is NOT bliss! In actuality, ignorance only leads to more suffering—for both your patient and yourself. Specifi cally, this book has been developed to help the primary-care physician deal with patients with substance-use disorders. Because you are reading this book, you probably have a few of these patients in your practice and, by now, you may be experiencing a great deal of frustration because of their behaviors. However, chances are, you never received much (if any) formal training in the area of addiction and you may feel ill-equipped to evaluate and manage these extremely diffi cult patients. You are not alone! Even the very best physicians can become fed up when it comes to treating alcoholic/addicted patients. By reading this “user- friendly” book, we believe you will gain important and necessary skills which can aid in helping you to feel more in control and less distressed when working with your addicted patient population. It is expected that through the informa- tion presented in this book, you will: x Preface • B ecome more knowledgeable about the latest fi ndings regarding the pathophysiology and genetic factors involved in the development of a substance use disorder (SUD); • Gain greater skills regarding accurate diagnosis of substance use, abuse and dependence; • G ain greater expertise in utilizing both pharmacologic and nonpharma- cologic interventions that can be administered in an offi ce-based setting to treat your addicted patients. How to Use This Book Following this introductory section, Chapter One focuses on the spectrum of addiction; i.e. defi nitions, a discussion of the “disease model,” pathophysiol- ogy and genetics, and common drugs of abuse. In Chapter Two, we describe “who” the addicted patient is and the underlying psychological processes common in addictive illness. Twelve-step programs, such as Alcoholics and Narcotics Anonymous, are also discussed in this chapter. Chapter Three pro- vides information about how to assess the presence of SUD, utilizing a variety of instruments, as well as how to obtain a reliable substance abuse history. In Chapter Four, you will fi nd a detailed overview of offi ce-based pharmacologic approaches to managing your patients with SUD. Also in this chapter, we have included defi nitive parameters to help guide your decision-making regarding your patient’s need for inpatient versus outpatient detoxifi cation. Chapter Five introduces brief, effective nonpharmacologic strategies, based on both cogni- tive-behavioral therapy and motivational interviewing, which you can utilize in an offi ce-based setting. Finally, Chapter Six provides case presentations and algorithms which we feel will aid you in gaining additional insight into these complex patients. A common slogan in the 12 Step programs is, “First Things First.” The development of knowledge and skills within a specifi c domain fi rst requires a basic & empathic understanding regarding the nature of the problem at hand; hence, we will now move on to discuss the spectrum of addictive disease. Heidi Allespach Pomm, PhD Raymond M. Pomm, MD References 1. The CASA National Survey of Primary Care Physicians and Patients. The National Center on Addiction and Substance Abuse at Columbia University (CASA) 2000. 2. Califano JA Jr. Substance abuse and addiction–the need to know. Am J Public Health. 1998 Jan;88(1):9–11. 3. Miller NS, Sheppard LM. The role of the physician in addiction prevention and treat- ment. Psychiatr Clin North Am. 1999 Jun;22(2):489–505. Contents Foreword by Mark S. Gold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 1 Spectrum of Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2 The Addicted Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3 Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4 Pharmacologic Offi ce-Based Interventions . . . . . . . . . . . . . 55 5 Nonpharmacologic Offi ce-Based Interventions: Cognitive- Behavioral Therapy and Motivational Interviewing . . . . . 87 6 Case Presentations and Algorithms for Management . . . . 110 Appendix 1 Into Action: Putting Cognitive-Behavioral Therapy and Motivational Interviewing into Practice . . . . . . . 118 Appendix 2 Sample Informed Consent and Medication Management and Treatment Agreements . . . . . . . . . . . . . . . . . 142 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151