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Quick & Dirty: Addiction Medicine in Primary Care

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by

Arash Zohoor

on 6 October 2016

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Transcript of Quick & Dirty: Addiction Medicine in Primary Care

Quick & Dirty:
Addiction Medicine

Haunted Forest
of Addiction
Motivation
Medications
Counselling
Goal:
Less Suffering

Thank you!
Arash Zohoor
zohoora@gmail.com
Addiction?!
"Drug addiction is a chronic, progressive, relapsing brain disease characterized by compulsive drug seeking and use despite harmful consequences"
APA
4 Cs
Compulsion
Mindset
Screening
Screening Tools
In the past year, how many times have you used [x]?
Evaluation
The Pain
Cravings
Loss of Control
Consequences
STOP
GO
DOPAMINE
The Brain Part
No Grant/Research Support
No Speakers Bureau/Honoraria
No Consulting Fees
No Relationships to Declare
No Commercial Support
tl;dr: No Real or Perceived Conflicts
Disclosures
Calm
Caring
Creative
32 seconds to complete
Any substance abuse:
Sensitivity
Specificity
90%
94%
Severe substance abuse:
100%
94%
Tobacco, Alcohol, Marijuana,
Illegal drugs, Prescription, OTC , Inhalants, Herbs
JAMA Pediatrics Sep 2014 168(9)
200 teenagers, 12-17 years old
None: once-twice
Mild-Moderate: Monthly
Severe: Weekly or more
To Screen or not to Screen
Pregnancy
Elderly
Teenagers
Neglect
'Emptiness'
Trauma
Collaborative Empiricism
Presence and level of intoxication
Suicidal or homicidal ideation
Physiologic dependence
Morbidity by Domain
Significant others
Social
Financial
Legal
Work/School
Physical
Psychiatric Comorbidities
Readiness for Change
Prior treatment patterns
Medical Cormobidities
Stages of Change
Maintenance
Precontemplation
Contemplation
Preparation
Action
Consciousness Raising
Lifestyle Reevaluation
Self-re-evaluation
Self-liberation
Contingency Management
Helping Relationships
Counterconditioning
Stimulus Control
Motivational
Interviewing
MI Elements
MI Spirit
MI Principles
Change Talk
OARS
Motivational
Interviewing
Resist the righting reflex
Understand the motivation
Listen
Empower
Collaboration
Autonomy
The client makes arguments
for change
Open-ended questions
Affirmations
Reflective listening
Summaries
Withdrawal
Maintenance
Nicotine
Bupropion
Alcohol
Sedative-Hypnotic
Opioids
Nicotine
Alcohol
Sedative-Hypnotic
Opioid
Stimulant
Marijuana
Varenicline
Nortriptyline
Clonidine
Not helpful: SSRIs, SNRIs, Carbidopa/Levodopa, Naltrexone
Disulfiram
Naltrexone
Acamprosate
Anticonvulsants
Baclofen
Ondansetron
Benzodiazepine Taper
Anticonvulsants
Methadone
Buprenorphine
Clonidine
Naltrexone
Basics
Focus directly on substance abuse
Use motivational interviewing
Focus on coping skills
Change reinforcements
Manage painful affects
Improve interpersonal function
Foster treatment alliance
Assign homework
Modalities
Determinants of Relapse
Self-Efficacy
Outcome Expectancies
Craving
Motivation
Coping
Emotional States
Interpersonal Determinants
Distal Risks
Cognition
Withdrawal
Affect
Coping
Substance
Abuse
Tonic Processes
High Risk Situations
(Contextual factors)
Phasic Responses
Perceived
Effects
Dynamic Model of Relapse
Less Suffering
Abstinence
Sobriety
Non User
Cocaine: 10 day sober
Cocaine 100 day sober
Welcome!
Arash Zohoor MD CCFP
Brantford, Ontario
Dose Equal to 30 mg
Phenobarbital (mg)
Benzodiazepines
Alprazolam
Chlordiazepoxide
Clonazepam
Clorazepate
Diazepam
Lorazepam
Oxazepam
Temazepam
Triazolam
0.5-1
25
1-2
7.5
10
2
10-15
15
0.25
Stimulants
Desipramine
D-amphetamine SR
Nicotine Replacement Therapy
Cigarettes/day
Patch Dose (mG/d)
<10
10-20
21-40
>40
7-14
14-21
21-42
42+
Modafinil
Varenicline
Naltrexone
150 mg BID: $35*
1 mg BID: $143*
75 mg OD: $33*
666 mg TID: $187
8 mg BID: $414
60 mg OD: $226*
16 mg OD: $355*
100 mg OD: $45*
60 mg OD: $275*
200 mg OD: $78
1 mg BID: $143*
Interpersonal Therapy
CBT Approaches
Brief Advice
Acceptance-Commitment Therapy
Self Image
Behavioural
N-acetylcysteine
Citalopram
Bupropion
Naltrexone
50 mg OD: $220
1500 mg OD: $205
40 mg OD: $25*
$135
0.1 mg TID: $30*
250 mg OD: $46
50 mg OD: $220
0.1 mg TID: $30*
50 mg OD: $220
50 mg OD: $220
150 mg BID: $35*
Full transcript