`Integrating:

12-Step Spirituality,21st Century Psychopharmacology,

Addiction Psychiatry,and

Dual Diagnosis ConceptsIn Addiction Treatment Settings

By

GARRETT O’CONNOR, M.D.

The Radisson-Miyako HotelSan Francisco

October 8-11, 2003

ADDICTION MEDICINE:STATE OF THE ART 2003

`

ADDICTION

IS A

BRAIN

DISEASE

`THE

RE-ENTRY

OF PSYCHIATRY

INTO THE

ADDICTION

TREATMENT FIELD

`ADDICTION IS A

CUNNINGPOWERFULBAFFLING

DANGEROUSDEVIOUS

UGLY&

HIDDENDISEASE

`

BUT

MORE THAN

A

DISEASE,

ADDICTION IS

A

WAY OF LIFE

`

RECOVERYIS

ALSOA

WAY OF LIFE

`ADDICTION

IS

THE GREAT IMITATOR

OF

ALL DISEASES

(Especially Psychiatric Ones)

`

• 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 IllnessOr Severe Personality

DisorderIn the same Person)

`

DUAL DIAGNOSIS

Is Important Because of:

• Its Arguably High Prevalence,

(b) Its Prognostic Significance

(c) The Important Rx. Implications of Making a

Correct Diagnosis

`

THEDIFFERENTIAL

DIAGNOSISBETWEEN

CO-OCCURRINGPSYCHIATRIC

DISORDERSAND

ADDICTIVE DISEASEIS A

VITAL CLINICAL DETERMINATION!

`DANGER!

• Prescribing Psychotropic Medications for the Wrong Diagnosis

• Failure to Prescribe PsychotropicMedications for the Right Diagnosis

`A MISTAKE

EITHER WAY

CAN LEAD TO

EVENTUAL RELAPSE

AND EVEN

DEATH!

`

INTEGRATINGTWO 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.

`I2-STEP ORIENTEDTREATMENT

PROGRAMS MUSTNOT

ALLOWBIOLOGICALPSYCHIATRY,

SCIENCE, AND

PSYCHOTROPIC MEDICATIONS TO

BECOME THEIRHIGHER POWER

`ABALANCED

APPROACH

IS

ESSENTIAL

`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.

`

INTEGRATINGFIVE CULTURES

ACTIVE ADDICTION

ABSTINENCE-BASEDTREATMENT

AND12-STEP SPIRITUAL

RECOVERY

COGNITIVE-BEHAVIORALTREATMENT

DYNAMIC PSYCHIATRY

BRAIN RESEARCH &BIOLOGICAL PSYCHIATRY

`

EACH ONEOF

THESE FIVE CULTURES

HOLDS DIFFERENT, AND OFTEN

CONFLICTING, BELIEFS ABOUT THE NATURE OF ADDICTION, AND

HOW IT SHOULD BE TREATED

`

THEREFORE,

THE NATURE, TASK, ROLE,

BOUNDARIES,

AND AUTHORITY

OF EACH CULTURE

MUST BE DEFINED,

UNDERSTOOD,

AND ACCEPTED

`FOR EXAMPLE,

DIFFERENTIATE

TREATMENT

FROM

RECOVERY!

`DIFFERENTIATE

ABSTINENCE

FROM

HARM REDUCTION

FROM

CONTROLLEDDRINKING

`

SOME

“DIFFICULT”

ELEMENTS

OF

12-STEP

SPIRITUALITY

`THE

SPIRITUAL CONCEPT

OF A

HIGHER POWER

`

ACCEPTANCE

AND

SURRENDER

`THE

INFLATED

ALCOHOLIC

EGO

MUST BE

DEFLATED

AT DEPTH(Bill W.)

`

SELECT

AND

SUBMIT

TO A

SPONSOR

`SERVICE IN AA

COMMITMENTS

12-STEP WORK

WORK WITHNEWCOMERS

H & I

G.S. REPRESENTATIVE

SPONSORSHIP

CENTRAL OFFICE

`SOBRIETY

IS AN

UNNATURAL

STATE

FOR

ADDICTS

`SOBRIETY

IS

THE

#1

CAUSE

OF RELAPSE

`

GIFTS FOR RECOVERING ALCOHOLICS

(Opportunities for Spiritual Growth)

•Suffering!•Humiliation!•Disappointment!•Disillusionment!•Betrayal!•Loss!•Extreme Guilt & Shame!•Abandonment!•Failure!•Success!

`THE

SPIRITUAL

VALUE

OF

SUFFERING

`

`THE

RE-ENTRY

OF PSYCHIATRY

INTO THE

ADDICTION

TREATMENT FIELD

`

ABOUT 50%OF

ALCOHOLIC/ADDICTS ADMITTED

TOTHE BETTY FORD

CENTERARE ALREADY ON PSYCHOTROPIC

MEDICATIONS PRESCRIBED BY PCP’S

OR PSYCHIATRISTS, OFTEN WITHIN 3-6

MONTHS PRIOR TO ADMISSION

`

•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.

`

• PSYCHIATRYAND PHARMACEUTICAL

COMPANIESBELIEVED THEY COULD

ENHANCE THE EFFECTIVENESS OF

12-STEPTREATMENT & RECOVERY

• FROM LATE 80’S,MAJOR ADDICTION MEDICINE

SOCIETIES (AAPA; ASAM; CSAM; Etc.)

ACCEPTED “EDUCATIONAL”MONIES FROM DRUG

COMPANIES

`• DRAMATIC

BREAKTHROUGHS!

• NEW FRONTIERS!

• REVOLUTIONARY ADVANCES!

• EVIDENCE-BASED

TREATMENT APPROACHES

`DRUGS USED AFTER

DETOXIFICATION INTREATMENT OF ADDICTION

• Disulfiram• Naltrexone• LAAM• Acamprosate• Methadone• Buprenorphine• Mood Regulators• Anti-depressants• Sedative-hypnotics (Rarely, if ever)• Anti-psychotics (When indicated)

`

•DUAL DIAGNOSIS

• PSYCHOTROPICMEDICATIONSIN RECOVERY

• BOO-HOO FOR 12-STEP!

(NO “SCIENTIFIC” EVIDENCE!)

`ON THE CONTRARY,

RECENT RESULTSFROM

PROJECT MATCHSUGGEST THAT

AAMAY BE THE MOST

EFFECTIVEAPPROACH

FORLONG-TERMABSTINENCE

ANDSOBRIETY

`POTENTIALLY

USEFUL & VALID

NEW

TECHNOLOGIES

MAY BE EXPERIENCED

BY STAFF AS

THREATS

TO THE

12-STEP CULTURE

`AFTER DETOXIFICATION,PSYCHOTROPIC

MEDICATIONS SHOULDBE

PRESCRIBEDFOR ALCOHOLICS AND

OTHER ADDICTS IN RECOVERY

ONLY WHEN THE DIAGNOSIS

OF DUAL DISORDERHAS

BEENCONFIRMED

`

NEGATIVE ATTITUDES IN AAABOUT

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 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• LACKS ACCOUNTABILITY• UNCOOPERATIVE • COMPETITIVE• NON-INTELLECTUAL • FREE

`

POSITIVE ATTITUDES IN AAABOUT PSYCHIATRISTS,

PSYCHOTHERAPYAND 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 PSYCHIATRY ABOUT AA

• SUPPORTIVE• LIFE-SAVING• INDISPENSABLE• DIVINELY INSPIRED• COOPERATIVE• COMPLEMENTARY • REVOLUTIONARY• ADMIRATION• GRATITUDE

`

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

`

UNDERSTANDING RECOVERYAND 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

`

SHAME

`PERSONAL,

PROFESSIONAL,

AND

MEDICAL

SHAME

`

PRINCIPLES FOR INTEGRATING 12-STEP AND DUAL DIAGNOSIS PROGRAMS

1. Needs Assessment2. Establish Vision & Mission3. Survey Staff Attitudes4. Create Policies and Procedures5. Educate Referents6. Adequate Staff Education7. Cross-Training for Staff8. Capability for Longer Stay9. Double Trudger’s Groups10. Integrated or Segregated

Treatment Tracks?11. Expert Differential Diagnosis12. Drug-free Observation Period13. Experienced Medical and

Psychiatric Direction

`CRFANTAGONISTS

MAYINTERRUPT STRESS

CYCLES, BLOCK DOMINO

EFFECTS, AND

PREVENTBIOLOGICAL CASCADING

INTODEEPER LEVELS

OFSTRESS

`IN THE MEANTIME,EVERY ONE HOPES

THATSOMETHIHG

ALREADY OUT THERE(a drug, that is)

WILLBE FOUND

TO BE EFFECTIVE!

`URGENT

NEEDTO FORMALLY

ADDRESS THESECULTURAL

DIFFERENCES WITHIN THE

FIELD TOFACILITATE

BENCH TO BEDTO COMMUNITY TRANSLATIONAL

INITIATIVES

`

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