i gave up opiates and alcohol, now i’m “addicted” to food? · report ever being cured. apa...

I Gave Up Opiates and Alcohol,

Now I’m “Addicted” To Food?

Kevin Wandler, MD

CMO Advanced Recovery Systems

October 19, 2017

IntNSA



The Neuroscience of Substance Use Disorders and Food Addiction.”

Kevin Wandler, MD

Chief Medical Officer

Advanced Recovery Systems

October 19, 2017

ONE TEAM

ONE VISION

The Recovery VillageThe Recovery Village-Palmer Lake

Next Generation VillageOrlando Recovery Center

Blue HorizonNext Step Village

The Recovery Village-RidgefieldIAFF Center of Excellence

The Recovery Village Columbus

Kevin Wandler, MDChief Medical Officer

[email protected]

Goals and Objectives

After this presentation the attendee will:

� 1. Review basic neuroscience of the reward system

� 2. Understand the similarities and differences between

patients with an Eating Disorder and a Substance Use

Disorder.

� 3. Become familiar with screening tools for substance

use disorders.

� 4. Be aware of the appropriate treatment for dually-

diagnosed patients.



Kevin Wandler, MD


October 19, 2017

IntNSA

The Neuroscience of Eating

Disorders and Addiction

Why discuss ED with

Substance Abuse??� Eating Disorders have the highest mortality rate of

any mental illness 6-7 %.

� Mortality rate associated with Eating Disorders is 12 times higher than the death rate of ALL causes of death for females ages 15-24 and the third most chronic illness among adolescents.

� www.state.sc.us/dmh/anorexia/statistics.htm

� Five to ten percent of patients with anorexia nervosa die within ten years of onset, 18-20 percent die within twenty years of onset, and only 50 percent report ever being cured.

APA Practice Guidelines 2006

Prevalence of eating disorders and substance use disorders in females:

• Up to 50% of individuals with an ED

abuse alcohol or illicit drugs compared

with 9% in the general population

• Up to 35% of alcohol or illicit drug abuses

have eating disorders compared to 3

percent of the population

Food for Thought: Substance Abuse and Eating Disorders, The

National Center on Addiction and Substance Abuse at Columbia

University, December 2003.



Kevin Wandler, MD


October 19, 2017

IntNSA

New York Times September

2017

Drug overdoses killed ~64,000 people in the US last year.

2015 ~52,400 people died from drug overdoses

Eating Disorder Prevalence

by Disorder??

Adults only: National Comorbidity Survey 18 yrs and older:

Anorexia and

Bulimia

1.5% of population 1.6 million adults

Binge Eating

Disorder

2.6 % of

population

2.8 million adults



Kevin Wandler, MD


October 19, 2017

IntNSA

ASAM DefinitionASAM Definition

Short Definition of Addiction:

�ADDICTION is a primary, CHRONIC DISEASE of BRAIN reward, motivation, memory and related circuitry.

�Dysfunction in these circuits leads to characteristic

biological, psychological, social and spiritual

manifestations.

�This is reflected in an individual pathologically pursuing

reward and/or relief by substance use and other

behaviors.

ASAM DefinitionASAM Definition

Short Definition of Addiction (cont.):

�Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.

�Like other chronic diseases, addiction often involves cycles of relapse and remission.

�WITHOUT TREATMENT or engagement in recovery activities, ADDICTION is progressive and CAN RESULT IN disability or premature DEATH.

DSM-V Definition: Substance Use Disorders

1. Using larger amounts or over a longer period of time than intended.

2. Persistent desire or unsuccessful efforts to cut down or control

3. Great deal of time spent in obtaining, using, and recovering from

4. Craving or a strong desire or urge to use

5. Recurrent use resulting in failure to fulfill major role obligations

6. Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by use

7. Important social, occupational, or recreational activities are given up or reduced because of use

8. Recurrent use in physically hazardous situations

9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problems that is caused or exacerbated by use.

10. Tolerance defined by need for increased amounts to achieve desired effect or markedly diminished effect with continued use of the same amount

11. Withdrawal either with withdrawal symptoms, or continued use to relieve or avoid withdrawal



Kevin Wandler, MD


October 19, 2017

IntNSA

DSMDSM--V Definition: Substance V Definition: Substance

Use DisorderUse Disorder

Mild: Presence of 2-3 symptoms

Moderate: Presence of 4-5 symptoms

Severe: Presence of 6 or more symptoms

DSM-V Definition: Substance Use Disorders (Modified to Eating Disorder Behaviors)

1. Participation in Eating Disorder behaviors over a longer period of

time than intended.

2. Persistent desire or unsuccessful efforts to cut down or control

Eating Disorder Behaviors

3. Great deal of time spent in obtaining, using, and recovering from

Eating Disorder behaviors

4. Craving or a strong desire or urge to Participate in Eating Disorder

behaviors

5. Recurrent Participation in Eating Disorder behaviors resulting in

failure to fulfill major role obligations

6. Continued Participation in Eating Disorder behaviors despite

persistent or recurrent social or interpersonal problems caused or

exacerbated by use

DSM-V Definition: Substance Use Disorders (Modified to Eating Disorder Behaviors)

7. Important social, occupational, or recreational activities are given

up or reduced because of Eating Disorder behaviors

8. Recurrent Participation in Eating Disorder behaviors in physically

hazardous situations

9. Continued Participation in Eating Disorder behaviors despite

knowledge of having a persistent or recurrent physical or

psychological problems that is caused or exacerbated by use.

10. Tolerance defined by need for increased Participation in Eating

Disorder behaviors to achieve desired effect or markedly

diminished effect with continued use of the same amount

11. Withdrawal either with withdrawal symptoms, or continued use to

relieve or avoid withdrawal



Kevin Wandler, MD


October 19, 2017

IntNSA

Circuits Involved In Drug Abuse and Addiction

All of these brain regions must be considered in developing strategies to effectively treat addiction


Inhibitory/ Control

PFC – prefrontal cortex

ACG – anterior cingulate gyrus

Motivation/ Drive

OFC – orbitofrontal cortex

SCC – subcallosal cortex

Reward/ Saliency

NAc – nucleus accumbens

VP – ventral pallidum

Memory/ LearningHipp – hippocampus;

Amyg – amygdala

As with Classical Addictions,

Eating Disorders…

� Begin with experimentation—

� with diets, starvation, and self-induced vomiting… only a small % lose control

� Lead to a chronic compromised nutritional and medical state

� Have a chronic relapsing course

� Have tragic outcomes

National Center on Addiction and Substance Abuse (CASA) at Columbia University (2003) Food for Thought: Substance Abuse and Eating Disorders


Eating Disorders…

� Very Resistant to Treatment

� Long Term Illness

� Relapses

� Life Threatening

� Increased Risk for Suicide

National Center on Addiction and Substance Abuse (CASA) at Columbia University (2003) Food for Thought: Substance Abuse and Eating Disorders



Kevin Wandler, MD


October 19, 2017

IntNSA


Eating Disorders…

� Have the three C’s with eating disorder behaviors

� Compulsive craving (drive for thinness, compulsive behaviors of exercise, binge/ purge, etc)

� Loss of control of behaviors

� Continued “use/ behaviors” despite negative consequences

� Cognitive impairment

� Negative impact on all organ systems

� Issues with self esteem

� Mood and anxiety disorders

� Trauma history

� High incident of personality disorders


Eating Disorders…

� Maladaptive Behaviors (DBT-Ineffective

behaviors)

� To escape

� To avoid

� To numb

� To manage mood, anxiety, trauma

� To punish negative self

Differences…

VS.

� Tolerance, physical dependence and withdrawal are not seen in ED with food,

possibly exercise.

� Abstinence of Eating Disorder behaviors vs.

normalization of eating.

� Significant differences in the field with psychotherapy, medications interventions and

self help.



Kevin Wandler, MD


October 19, 2017

IntNSA

DSM-5: Eating Disorders

The Diagnostic and Statistical Manual (DSM-5) currently recognizes three main categories of eating disorders:

Anorexia Nervosa

Bulimia Nervosa

Binge Eating Disorder (BED)

Anorexia Nervosa DSM-5� A. Restriction of energy intake relative to requirements leading to a

significantly low body weight

� B. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

� C. Disturbance in the way in which one's body weight or shape isexperienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

� Binge–Eating/Purging or Restricting

Partial Remission /Full Remission

� Mild BMI > 17 kg/m2

� Moderate BMI 16-16.99 kg/m2

� Severe BMI 15-15.99 kg/m2

� Extreme BMI <15 kg/m2



Kevin Wandler, MD


October 19, 2017

IntNSA

Facts about Anorexia

and Substance Abuse

� Surprisingly—most patients with anorexia nervosa use the least amount of drugs compared to BED and BN.

� Nicotine

� Caffeine

� Cocaine/ Stimulants

� Little alcohol, marijuana

� Little opiates, meth

DSM-5 Bulimia Nervosa1. Binge eating

A. Eating an amount of food definitely larger than what most people eat

B. Sense of lack of control

2. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications, fasting; or excessive exercise.

3. Above occur 1x / week for 3 months

4. Body image issues

5. Does not occur during Anorexia Nervosa

Partial Remission /Full Remission

� Mild– an average of 1-3 episodes of inappropriate compensatory behaviors per week

� Moderate– an average of 4-7 episodes/ week

� Severe– an average of 8-13 episodes/ week

� Extreme– an average of 14/week

Facts about Bulimia

Nervosa and Substance

Abuse

� Bulimia is most commonly associated with substance abuse.

� Those who abuse laxatives tend to have more psychopathology

� Much attempt at emotion regulation

� Women who BN and Alcohol Dependence have higher rates of suicide attempts, anxiety, personality disorders, conduct disorders and other drug dependencies.



Kevin Wandler, MD


October 19, 2017

IntNSA

Binge Eating Disorder DSM-5

Must have all primary

criteria!!

� Recurrent episodes of binge eating

� 1. Eating an amount of food that is definitely larger than what most people would eat. (and)

� 2. A sense of lack of control

� Binge (must have 3 out of 5)

1. Eating much more rapidly than normal

2. Eating until feeling uncomfortably full

3. Eating large amounts of food when not feeling physically hungry

4. Eating alone because of feeling embarrassed by how much one is eating

5. Feeling disgusted with one self, depressed, or very guilty afterwards

� Distress, On average once a week for 3 months

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Binge Eating Disorder DSM-5

Must have all primary

criteria!!� Mild 1-3 binge-eating episodes per week

� Moderate 4-7 binge-eating episodes per week

� Severe 8-13 binge-eating episodes per week

� Extreme greater than 14 binge-eating episodes

per week.

American Psychiatric Association. (2013). Diagnostic and

statistical manual of mental disorders (5th ed.).



Kevin Wandler, MD


October 19, 2017

IntNSA

How to weigh yourself correctly…

Obesity—The Problem




Inhibitory/ Control



Motivation/ Drive



Reward/ Saliency




Amyg – amygdala



Kevin Wandler, MD


October 19, 2017

IntNSA

34

Are Eating Disorders

an

Addiction???

YES?? NO!!! Maybe!?!?

DOPAMINE� Whenever an experience produces more pleasure than

expected—your brain releases Dopamine (DA)

� Drugs of abuse (e.g., cocaine, alcohol, nicotine) release

dopamine and other chemicals

� Dopamine regulates food intake through the meso-limbic

circuitry of the brain— THE PLEASURE CENTER OF THE BRAIN

� Starving, bingeing and exercise all serve as “drug delivery devices” since they increase circulating levels of ß-endorphins that are chemically identical to exogenous opiates.

� Endorphins are potentially addictive because of their ability to

stimulate DA in the brain’s mesolibic reward centers.

(i.e. hooked on exercise)

Huebner HF (1993) Endorphins, Eating Disorders and Other Addictive Behaviors. New York: W.W. Norton & Co.

DOPAMINE

Neurotransmitter

or Drug

Eating Disorder

Behavior

Dopamine

Amphetamine/Cocaine

& Nicotine ↑ DA

Anorexia/ OCD ↑ DA

Purging ↑ DA

Antipsychotic ↓ DA

Obesity ↓ D2 Receptors

↓Eating

↓Eating

↓Eating

↑ Eating/ Improvement with OCD Behavior

↑ Eating



Kevin Wandler, MD


October 19, 2017

IntNSA

Natural Rewards and

Dopamine Levels

Adapted from: DiChiara et at, Neuroscience, 1999

Adapted from Fiorino and Phillips, J Neuroscience, 1997

substantia nigrasubstantia nigra

locus coeruleuslocus coeruleus

Normal Pleasure Response

nucleus accumbensnucleus accumbens

VTRVTR

Pleasure/Motivation Response

Increased Dopamine Release

YUM!!


locus ceruleuslocus ceruleus

Brain Reward PathwayBrain Reward Pathway

Psychoactive Addictive

Drugs Act on this Pathway

Psychoactive Addictive

Drugs Act on this Pathway



Kevin Wandler, MD


October 19, 2017

IntNSA

Effects of Drugs on Dopamine

Levels

Adapted from: DiChiara and Imperato, Proceedings of the National Academy of

Sciences USA, 1988, courtesy of NoraD Volkow, MD

Effects of Amphetamines on

Dopamine Levels

Adapted from: DiChiara and Imperato, Proceedings of the National

Academy of Sciences USA, 1988, courtesy of NoraD Volkow, MD



Kevin Wandler, MD


October 19, 2017

IntNSA

Dopamine vs. Serotonin

Pleasure(WOW!!!) vs. Happiness(YUM!)

�Dopamine produces a feeling of pleasure

�Serotonin produces a feeling of well

being

�Difference between pleasure and

happiness (short lived vs big picture)

�Happiness--Developing skills, interest,

relationships, meaning (“getting a life”)

PleasurePleasure

“I feel good”“I feel good”

BoredBored

AnhedoniaAnhedonia

InterestedInterested

“I feel negative”“I feel negative”

NORMAL RANGENORMAL RANGE

DysphoriaDysphoria EuphoriaEuphoria

Pleasure Scale

Brain Reward Pathway



Wow!!!

Dopamine surge!!!

Drug



Kevin Wandler, MD


October 19, 2017

IntNSA




Wow!!!

Dopamine surge!!!

Drug

Dopamine, Serotonin, Norepinephrine…

Reward Pathway

The “Wow!!!” is a big reason

people take drugs but other

things also happen…

Drugs act on the


Reward Pathway

Emotional & behavioral

learning

Control of body movement

Early learning and

memory processing

Attention states and

automatic function

Areas



Kevin Wandler, MD


October 19, 2017

IntNSA

Continued Drug Use – Spine Development



Wow!!!

Structural changes

DrugDrug

Continued Drug Use



Wow!!!

A “molecular switch” is thrown in the brain

• Sensitization, Craving and Relapse • Loss of control over drug use

• Compulsive drug seeking behavior



Kevin Wandler, MD


October 19, 2017

IntNSA

Incentive Salience—

Wants/ Cravings

� Salience—being noticeable

� Incentive salience is a type of motivation created in the brain because it has developed an association between a certain stimuli and reward. “I want and I want it now!!”

� In the case of addiction this stimuli will be whatever drug the individual is using.

� Incentive salience is a far greater incentive than merely liking something.

Incentive Salience –

Wants/ Cravings

� Previously neutral stimuli are assigned incentive salience.

�Smelling cigarette smoke can trigger a craving for nicotine

�Drug paraphernalia now trigger drug craving.

�Driving in or near a neighborhood where drugs were purchased triggers craving

�Thus, if a person's addiction subsides and the individual subsequently encounters one of these secondary reinforcers, a craving for that drug may reappear.



Kevin Wandler, MD


October 19, 2017

IntNSA

Drive

OFC

Drive

OFCSaliency

NAc

Saliency

NAc

Memory

Amygdala

Memory

Amygdala

Control

CG

Control

CG

Non-Hijacked Brain

Non-Hijacked Brain

HijackedBrain

HijackedBrain

STOPSTOP

GOGO

DriveDrive

MemoryMemory

Saliency Saliency

ControlControl

DriveDrive

MemoryMemory

Saliency Saliency

Adapted from: Volkow et al.,

J Clin Invest 111(10):1444-1451, 2003.

Adapted from: Volkow et al.,

J Clin Invest 111(10):1444-1451, 2003.




Inhibitory/ Control



Motivation/ Drive



Reward/ Saliency




Amyg – amygdala

Medications for Relapse PreventionMedications for Relapse Prevention

Interfere with conditioned memories (craving)

Interfere with conditioned memories (craving)Counteract stress responses that lead to relapse

Counteract stress responses that lead to relapse

Strengthen reinforcing effects of non-drug reinforcers

Strengthen reinforcing effects of non-drug reinforcers

Strengthen inhibitory controlStrengthen inhibitory control

Strengthen prefrontal-striatal communicationStrengthen prefrontal-striatal communication

Addicted Brain

Drive

Control

Saliency

Memory

GOSTOPSaliency Drive

Control

Memory

Non-Hijacked Brain

Adapted from: Volkow et al., J Clin Invest 111(10):1444-1451, 2003. Adapted from: Volkow et al., J Clin Invest 111(10):1444-1451, 2003.



Kevin Wandler, MD


October 19, 2017

IntNSA

Genetic Contribution for

ED/SUD:

� Journal of Studies on Alcohol and Drugs

8/2013 showed that if you have a gene for

alcoholism or alcohol dependence, you are 38-53% at risk for developing bulimia—

specifically binge eating and purging with

vomiting, laxatives and diuretics

What Contributes to the

Development of an ED or SUD?

Contributor Eating Disorders Substance Use Disorders

Genetics Account for about

40-60 % of

contribution

Account for about

40-60 % of

contribution

Females are 5-8

times more likely

to develop an ED

than Males

Males are twice as

likely as females

to have alcohol or

drug addiction

Low self esteem

Perfectionism

Anxiety

Family history

Low self esteem

Impulsivity

Anxiety

Family history




Environment Family's beliefs

and attitudes

toward food and

behaviors

Family's beliefs

and attitudes to

drug use

Peer group that

encourages

dieting, diet pills,

weight focused,

laxatives and

diuretics and SIV

Peer group that

encourages drug

use,

experimentation

Media Media



Kevin Wandler, MD


October 19, 2017

IntNSA




Environment Trauma Trauma

Epigenetics All the above and

more!!

All the above and

more!!

62

“Drugs” used by patients with

Eating Disorders

� Caffeine ↓ Eating ↑ Purge

� Diuretics ↑ Purge

� Diet pills ↓ Eating

� Ipecac ↑ Purge

� Laxatives ↑ Purge

� Water ↓ Eating ↑ Purge

Adapted from Roerig, et al 2003



Kevin Wandler, MD


October 19, 2017

IntNSA

Drugs used by patients with

Eating Disorders

Alcohol ↓ Eating ↑ Purge

Amphetamine/

Stimulants ↓ Eating

Cocaine/ Crack ↓ Eating

Marijuana ↑ Eating

Nicotine ↓ Eating

Adapted from Roerig, et al 2003

NICOTINE ADDICTION CYCLE

NEUROCHEMICAL AND RELATED

EFFECTS OF NICOTINE



Kevin Wandler, MD


October 19, 2017

IntNSA

E-CIGARETTES & YOUTH

SMOKING, SUBSTANCE USE

DISORDER AND MENTAL ILLNESS

Screening for Harmful

Alcohol and Drug Use

1. Screen everyone at risk.

2. Use validated screening tools.

3. Provide nonjudgmental feedback

with their results.



Kevin Wandler, MD


October 19, 2017

IntNSA

Single Question Screen for

Harmful Alcohol Use

� During the last year, how many times have you

had _____or more drinks in a day/setting:

� > five for men

� >4 for women

� > 4 if older than 65

� Positive screen is one or more items

Sensitivity 82%, Specificity (unhealthy use) 79%

Smith, PC et al, J Gen Int Med, 2010

What is a “Standard Drink”

72

CAGE Questionnaire:

•Have you ever felt the need to cut down on ….drinking/bingeing/purging/ ED Behaviors?

•Have you ever felt annoyed by criticism of

your … drinking/bingeing/purging/ ED Behaviors?

•Have you ever had guilty feelings about your…

drinking/bingeing/purging/ ED Behaviors?

•Have you ever gotten up in the middle of the

night or early in the morning to…drinking/bingeing/purging/ ED Behaviors?



Kevin Wandler, MD


October 19, 2017

IntNSA

AUDIT

10 questions

Less than 5 minutes

http://whqlibdoc.who.int/hq/2

001/who_msd_msb_01.6a.pdf

Just look up AUDIT Alcohol

AUDIT—Alcohol Use Disorders

Identification Test

What should be treated first?Best Practice: Treat all together

Modified from: Stahl, SM. Essential Psychopharmacology. CambriModified from: Stahl, SM. Essential Psychopharmacology. Cambridge, dge,

UK: Cambridge University Press 2013.UK: Cambridge University Press 2013.

Order of Treatment for Adults

Order of Treatment for Adults



Kevin Wandler, MD


October 19, 2017

IntNSA

Co-Morbid Conditions

Seen with Eating Disorders

� Diagnosis : NEDA

� ( OP/ Men and Women)

� Depression 50-75%

� Bipolar 12%

� Substance Abuse 49%

� ADHD 5-10%

� Anxiety Disorders 43%

� OCD 10-13%

� PTSD ------

� Personality Disorders 50-75%

� Borderline PD 2-60% Overall-Statistics from NEDA

Therapies for Our Patients

� 12 Step Recovery Programs

� Dialectical Behavior Therapy (DBT)/Cognitive Behavior Therapy (CBT)/ Cognitive Processing Therapy (CPT) for PTSD

� Eye Movement Desensitization and Reprocessing (EMDR) for trauma/Somatic Experiencing Therapy (SE) for anxiety

� Motivational Interviewing (MI)

� Family Therapy/ Family Based Therapy

� Nutrition Therapy

� Exposure Response Prevention (ERP)

Many of my patients just want a pill…..

Sorry,

there

are no

magic

pills.



Kevin Wandler, MD


October 19, 2017

IntNSA

Serotonin “Deficiency” Syndrome

Depressed mood

Anxiety

Panic

Phobia

Obsessions & Compulsions

Food Craving; Bulimia

Norepinephrine “Deficiency” Syndrome

Impaired attention

Problems concentrating

Deficiencies in working memory

Slowness of processing

Depressed mood

Psychomotor retardation

Fatigue

Fluoxetine (Prozac®)—Only FDA Approved Medication for Bulimia

� 20 mg fluoxetine� 45% reduction in binge eating

� 29% reduction in vomiting

� 60 mg fluoxetine� 67% reduction in binge eating

� 56% reduction in vomiting

Fluoxetine Bulimia Nervosa Collaborative Study Group,

Arch Gen Psychiatry 1992:49(2)139-147.



Kevin Wandler, MD


October 19, 2017

IntNSA

Vyvanse (Lisdexamfetamine®)—Only FDA Approved Medication for Moderate to Severe Binge Eating Disorder

50 or 70 mg of Vyvanse

� 83.7% reduction in binge days (study 1, n=190)


Placebo



� Dosing is 30 mg q AM then 50 mg or 70 MG

� Potential for addiction, do not give to a patient with a history of SUD, must monitor frequently!!

� There is a reason it is a C-II, need to rewrite scripts monthly and need frequent monitoring of patients!!

Psych Meds for EDs and Co-Occurring Disorders

Psychotropic medications used to treat EDs and co-morbidity:

Depression –

SSRIs(i.e., Prozac, Paxil, Zoloft, Luvox, Celexa, Lexapro)

Wellbutrin-SR & XL, Effexor-XR

Anxiety –

SSRIs

Low dose Atypical Antipsychotics

(i.e. Seroquel, Geodon and Abilify)

Try to avoid benzodiazepines-Xanax, Klonopin or Ativan

Mood Stabilizers

Lamictal, Topamax, Gabapentin

Painful and distorted thinking—body image disturbance

Low dose atypical antipsychotics – Zyprexa/ Abilify

Insomnia

Prudent use of Benadryl, Vistaril, Trazodone, Melatonin

Other Meds NOT under study…..

Anxiolytics are not effective for the treatment of ED!!!

(Xanax, Ativan, Klonopin, Valium, Librium)

Often prescribed by their psychiatrist or PCP for anxiety around meals!!

Does not help!! Does give them an Anxiolytic Dependency!!

Now they can be hospitalized for DETOX!!

Maine, et al, Treatment of Eating Disorders,

Bridging the Research-Practice Gap, Academic

Press 2010



Kevin Wandler, MD


October 19, 2017

IntNSA

Medications for Recovery from

Substances

Alcohol: (Data Conflicting on efficacy for AUD)

Naltrexone(ReVia)/ Depot Naltrexone (Vivitrol)

Acamprosate (Campral)

Disulfiram (Antabuse)

Naltrexone (ReVia)

Opiates: (Does patient need/ want to be off opiates?)

Naltrexone(ReVia)/ Depot Naltrexone (Vivitrol)

Buprenorphine/ Subutex

Buprenorphine + Naloxone/ Suboxone

Methadone

Nicotine: (Great evidence of helping!!)

Varenicline(Chantix)

Buproprion (Wellbutrin/ Zyban

Nicotine-gum, patch, lozenge, inhaler

Level of Care Criteria for ED (and SUD) Patients

� Level 1: Outpatient

� Level 2: Intensive Outpatient

� Level 3: Partial Hospitalization

� Level 4: Residential Treatment Center

� Level 5: Inpatient Hospitalization

APA Practice Guideline (2006)

Criteria for Treatment of

Substance Use Disorder

� For Substance Abuse—use ASAM criteria

� Insurance does not like to pay for IP detox except for Alcohol and Benzodiazepines

� ASAM Criteria updated for DSM-5 and includes emerging areas of focus—gambling and tobacco use disorders

www.asamcriteria.org/



Kevin Wandler, MD


October 19, 2017

IntNSA

Criteria for Hospitalization

for ED

The following warrants IP hospitalization—Wt. <85% IBW

HR < 40 bpm

BP < 90/60 mm Hg

Orthostatic BP changes

> 20 HR or >10 mmHg drop of diastolic BP

Temperature <97 degrees F

Hypokalemia K< 3mEq/L, electrolyte imbalance, hypophosphatemia, hypomagnesemia

Poorly controlled diabetes

Treatment of Patients with Eating Disorders,

Am J Psychiatry 163:7, July 2007

Supplement

“The sneaky prevalence of

substance abuse in nursing”Starr, K, JD, MSN, FNP-C, CEN, CPEN, Nursing 2015, March

2009 data—Monroe, et al

1% of employed RN’s were working with a known

substance abuse problem

Less that 1% of RN’s were in active substance abuse

treatment programs.

The ANA suggests closer to 10 %

Monroe and Kenega suggest between 14-20% or RN’s in

the US may have a problem with dependence or abuse

of drugs of abuse or alcohol.

IPN—CURRENT DATA

� REGISTERED WITH IPN-FLORIDA

� 27% of RN’s with a SUD “only” diagnosis.

� Our highest percentage is nurses who are Dual Diagnosed

(mental health & substance use d/o) which is almost

59%



Kevin Wandler, MD


October 19, 2017

IntNSA

Summary� Use of Substances along with an Eating Disorder

increase the morbidity and mortality to the patient

� Substance abuse is common with Eating Disorders

� Evaluation of the patient with an Eating Disordershould always carefully screen for Substance Use Disorder

� Evaluation of a patient with a Substance Use Disorder should always carefully screen for an Eating Disorder

� Treatment must be fully integrated!!

Questions?

Answers!

Thank you for all you do!!

Resources

� Advanced Recovery Systems:

� www.advancedrecoverysystems.com

� [email protected]

� Academy of Eating Disorders: www.aedweb.org

� Binge Eating Disorders Association: www.bedaonline.com

� International Association of Eating Disorder Professionals: www.iaedp.com

� National Eating Disorders Association: www.nationaleatingdisorders.org

i gave up opiates and alcohol, now i’m “addicted” to food? · report ever being cured. apa...

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