Specific Program Issues

Young Adult Addiction Young Adult Psychiatric

Chronic Disease• 90 % have had at least 3 interventions. • 95% have a life long psychiatric or addictive • disease.• Three stages of treatment Inpatient - Acute stabilization PHP/IOP - Acceptance and Surrender Outpatient - Integration and Maintenance• “First Things First” – Many exceptions to the

rule

Young Adult Addiction

• Once the addict discovers that using a substance provides pleasure, he has set up a Biological Conditioned Response.

• Any unpleasant or boring situation - he can get immediate relief.

• This response overrides any concerns about the consequences of using this substance (driving intoxicated, unsafe sex, stealing)

Genetically Prewired

• 10 to 15 percent of the general population meet the criteria for substance abuse and dependence

• You have to be genetically prewired to drink a fifth of vodka a day or to be mentally organized, motivated, and alert on 120mg of Roxycodone per day.

• 18 to 25% of young adults meet the criteria for a substance use disorder

• Frequent excessive binges in order to deal with anxiety or depression may be the reason for the increase but there are other factors

Genetics

• In order to have an addiction you have to have an assortment of genes very much like playing a slot machine.

• Three cherries or three sevens (777) are necessary to hit the jackpot.

• Addiction may skip a generation • Addiction may be generalized or very specific

such as Polysubstance Dependence or a specific substance such as Alcoholism

Environmental Factors

Environment Affects the Expression of the Addiction Genes

• Studies point out that children of alcoholics who are “genetically prewired” to be an alcoholic have a lower incidence of being an alcoholic.

• Unfortunately, the grandchildren have a higher incidence of active addiction than their parents.

Grandfathers

• Alfred died 66yo - Alcoholic• Jack died 54 yo - Alcoholic• Albert alive at 95 yo – Not Alcoholic

The Parents

Child

Addiction is a Medical Disorder

• the Limbic System does not care about consequences of actions.

• Its only purpose is to respond to a negative stimulus before you have time to think.

• The Cortex is that part of our brain that remembers all past consequences of behaviors.

• Its purpose is to assess the risk by reviewing what you have learned before you act.

Immaturity and Impulsivity

• Drugs and alcohol used in high doses disconnect the cortex from the Limbic system

• The limbic system is totally developed by the age of 18 yo but the cortex is still maturing until 25 yo.

• The young adult who is genetically prewired to be an addict and is active in his addiction, has limited impulse control for multiple reasons.

• He is an accident ready to happen.

“Imprinting”• Most opiate addicts can tell you the first time

they experienced their first opiate.• It takes one pill for the limbic system to

choose opiates as the answer to all problems.• It takes a year to replace it with recovery.• The limbic system is the source of primitive

drives and it is in the driver’s seat for an addicted young adult. The cortex is in the back seat making suggestions.

Better Opiates for Pain

• Oxycontin in the 90’s was a tremendous advancement as a more effective pain medication with less side effects.

• Availability of opiates dramatically increased giving chronic pain suffers relief.

• As the street price of these drugs have increased, it is cheaper to use heroin.

• Heroin has become more available with the increase demand.

Opiate Epidemic

• Dramatic increase in the # of young adults out of work, not married, unemployed, living with their parents, loss of purpose.

• Opiates readily available which gives a sense of wellbeing and stops all worries for 8% of population.

• Young adults with time on their hands plus opiates = an epidemic

• Over past 10 years opiate use has increased multifold.

Opiate Dependency is a Lethal Disease

• 8 patients died after discharge from the program from 2009 through 2014

• All had diagnosis of Opioid Dependence• One had done very well in the program and

completed the program and went to a ¾ way house

• 7 left the program before recommended, referred to extended care programs, or were administratively discharged

The Other Drugs• Marijuana• The Sedatives – Xanax, Klonopin• Alcohol• The Stimulants – Adderall, Cocaine, Meth• MDMA (molly, ecstasy)• The Synthetics – Spice, Bath Salts• Others – DM, Triple C’s, shrooms, LSD• The Dissociatives – PCP, Ketamine

Withdrawal

• Acute Withdrawal Syndrome (3 to 7 days) - Primary – Alcohol, Benzodiazepines, Opiates - Other – Marijuana, Stimulants, EcstasyPost Acute Withdrawal Syndrome(1 to 6months) - Sleep, limited Frustration tolerance, anxiety, depression, cravings, high relapse potential, “I am never going to feel good again!”

Relapse• Relapse as a concept Patients have many relapses in terms of going back to old addictive behaviors before they relapse on their substance• Relapse on the addictive drug -First use initiates the cravings -Second use solidifies it -Third use is large amount – OD and death• After a relapse do not keep it a secret, “What are you going to do about it!”

Special Treatment Considerations

Naltrexone and Vivitrol – Opiate and Alcohol -Cravings -Minimize Relapse -Dedication to the recovery processKlonopin and Xanax -Withdrawal Seizures – Depakote -Probable Anxiety Disorder Chronic Pain - Cymbalta, Neurontin, Lyrica, Muscle Relax

Eating Disorder – “Dual Diagnosis” Tract -Bulimia – The substance addiction cannot be treated unless you are treating the BulimiaSexual Addiction - Multiple sexual encounters - Pornography/InternetPost Traumatic Stress Disorder - ? 20% - <10% Dissociative

Marijuana• Arrested Development - #1 cause is Marijuana 1 – Social, emotional, and spiritual 2 – Ego development has “pieces” missing 3 – Partially adult and partially adolescent• Many patients have been using daily for 3 to 5

years. • You do not have to be genetically prewired to be

a daily user.• Makes psych problems worse and is dangerous

while in intensive treatment.

Psychiatric Disorder is #1 Relapse Risk Factor

• 90% of the Addictive patients have a separate Psychiatric Disorder

• Anxiety is the largest disorder followed by Depression

• 90% of the addiction patients do not have a Personality Disorder

• 90% of the patients that say they have ADHD do not have this disorder.

• Many patients in the program are diagnosed with a Psychiatric Disorder for the first time.

Hardest to Treat

• Methamphetamine addiction and Crack -Cravings are hard and constant - Wellbutrin - Dopamine -Post Acute Withdrawal symptoms has to be aggressively managed medically• Daily Suboxone use greater than 3 months.• IV heroin use greater than 6 months

Our Population at Ridgeview

Random sample of 50 admissions in 2011– 35% left AMA or Administratively– 35% were referred to extended treatment– 30% completed program and followed

recommendations– ~70% had primary dx of Opiate Dependency

• ~1/3 of all patients have dx of Marijuana Dep.• ~1/3 - Xanax Dep.• ~15 to 20% of patients – Alcohol Dep/Abuse• <10% – All other substances• >50% have at least two or more Drugs • >10% are addicted to anything they can abuse

and they should prob. not be on any medication unless absolutely necessary

2012 Outcome Study

• Included all patients who completed the program in 2012. Out of those we could contact:

• 57% in recovery• 43% had relapsed at least once• ~90% had a dual diagnosis• ~90% had to be “incentivized” to start

Young Adult Psychiatric(My best guess)

• 10 to 20% stay in Ridgeview residence• Primary diagnosis is Major Depression and

Generalized Anxiety Disorder• Next in frequency is Bipolar Disorder I and II• 15% have Borderline Pers.Dis.• 10% first Psychotic episode/Schizophrenia• 30% have criteria for Addiction Dependency• 10% purge, self-mutilate• 20% drink alcohol and smoke marijuana

• Aggressive medication treatment - Relief of symptoms but limited side effect - Psychosis, suicide, withdrawal may need inpatient• We try to manage abuse of drugs, self

mutilation, and purge but ------• Education of parents is critical to be able to do

interventions

September is Suicide Prevention Month

Tragically, death by suicide is not uncommon. Every year, more than 800,000 people die by suicide throughout the world; this roughly corresponds to one death every 40 seconds. Suicide is the fifth-leading cause of death among those aged 30-49, and the second leading cause of death in the 15-29 age group.

Know the Risk Factors Add them Together

• Highest risk is a > 50 yo widowed man with a major medical illness, with an addiction, living alone, has a chronic mental illness and a Borderline or a Dependent personality disorder, Asian, low or middle-income, not Catholic or Muslim.

• A young adult with a mental illness, addicted, living alone, a history of suicide, and a Borderline or Dependent Personality Disorder.

• Suicide rates vary enormously from country to country.

• India, where it is illegal, has 21 deaths per 100,000 people against a global average of 11.

• ¾ of suicides occur in low- and middle-income countries with highest numbers in central and eastern Europe and in Asia.

• Catholic- Muslim countries have lower rates.• Prior suicide attempt is the biggest risk factor.• ~75% of suicides are male in Britain

The #1 Cause of Death of Young Adults

• Opiate Dependency is now probably the #1 cause of death of the 15 to 29 age group.

• The catastrophic increase in overdoses from opiates over the past 10 years has happened so fast, that statistics cannot keep up with it.

• Differentiating suicide from overdose is many times difficult to do.

• Coupled with a major psychiatric illness, suicide or overdose is an extremely high probability without treatment.