Timberline Knolls Webinar
March 4, 2015
Addiction and Recovery in Women Kimberly Dennis, M.D., CEDS CEO/Medical Director Timberline Knolls, Lemont, IL
Outline • • • • • • • •
Maddie’s story Addiction defined Gender specific considerations Prevalence in women Assessment Treatment interventions Outcomes measures Recovery resources
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Case Study
Maddie • 37 yo CF, separated, mother of one with history of SUD, severe (alcohol, heroin, dilaudid, nicotine, valium, pregabalin); anorexia nervosa, binge-purge subtype; major depressive disorder; and PTSD. • Psychiatric history: reports depression and anxiety started as a teen, ED started at age 14; substance use began with nicotine age 16, alcohol age 18
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Maddie • • • • • • • • • •
Substance use history: Began with nicotine age 16, Alcohol age 18, Alcohol dependence by age 20; Received treatment at an addiction residential facility in 2000, sober until 2005, then relapsed on alcohol. Sober again until 2008; Married an alcoholic 2009; Opioid abuse started after C-section 2010 (Dilaudid), Heroin use began 2011 ED active throughout
Maddie continued • Medical/surgical history: – C-section 2000; – Pulmonary embolism 2013; – factor V Leiden deficiency; – fibromyalgia; – migraines • Family history: – Mother with EtOH use disorder, brother with depression, sober from cocaine addiction
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
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Maddie • Developmental/social history: – sexual molestation by paternal grandfather age 311yo; – witnessed domestic violence between mom and dad; – bullied in 5th grade (physical/verbal); – graduated from college with degree in psychology; – married 5 years ago, physically and verbally abusive relationship; – separated since 2012; – son is 4yrs old; – financially dependent on parents.
Addiction Defined
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Medical Model of Addiction • Expression of addiction (phenotype) is based on a genetic predisposition (genotype) that is influenced by environmental factors • Treatment compliance is similar to other chronic medical conditions (diabetes, hypertension, asthma) • Follows a relapsing and remitting course • Most effectively managed as a chronic disease • Both pharmacologic and psychotherapeutic interventions are evidence-based Koon, S. Primary Care Workshop. California Academy of Family Physicians and California Society of Addiction Medicine. April 14, 2005
Similarities with Other Chronic Diseases (DM-II, HTN, Asthma) • Genetic impact is similar • The contributions of environment and personal choice are comparable • Medication adherence and relapse rates are similar. • Long term maintenance treatments proven most effective.
McLellan, JAMA 2000
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
DSM-V • Activation of the brain’s reward system is key to problems arising from substance use • Profound reward feeling experienced with substance use leads to neglect of normal activities • Brain’s reward system when activated is similar across substances in producing euphoria, pleasure, “high”, pain relief.
Brain Circuitry: the Reward Pathway
• Major structures: the ventral tegmental area (VTA), the
nucleus accumbens and the prefrontal cortex.
• The VTA is connected to both the nucleus accumbens
and the prefrontal cortex, sending information to these structures via its DA-releasing neurons. • Pathway activated by a “rewarding” stimulus.
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Craving and Relapse • Priming: An introduction of even a tiny amount of the drug can cause intense cravings and imminent relapse • Conditioning: During substance use, patients also become hypersensitive to environment cues associated with use (associated smells, sights, location, sounds, stressors, people, etc.) • These cues can cause dopamine release AS IF A SMALL AMOUNT OF THE DRUG WERE TAKEN • Due to the stable biological changes, both priming and conditioning effects can persist for years
Koon, S. Primary Care Workshop. California Academy of Family Physicians and California Society of Addiction Medicine. April 14, 2005
•Hedonic Scale
Chronic Use: Hedonic Set Point “Feel good” •Normal Affective Response to Drugs/Alcohol
•Initially use to get high… “Cravings”
“Feel bad”
•Now use to “get normal”
•Dysregulated Set-Point Following Chronic Drug Use
Koob, Science, 1997
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
DSM-V • DSM-V recognizes that individuals are not equally or automatically vulnerable to developing SUDs • Some people have higher levels of impulsivity and adverse life experiences, which predispose to problems if exposed to drugs • Two groups of disorders: substanceinduced disorders and substance use disorders
Substance Use Disorders • Span a wide variety of problems arising from substance use, and cover 11 different criteria: – Taking the substance in larger amounts or for longer than intended – Wanting to cut down or stop using the substance but unable to – Spending a lot of time getting, using, or recovering from use of the substance
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
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Substance Use Disorders – Cravings and urges to use the substance – Impaired performance at work, home or school, because of substance use – Continuing to use, even when it causes problems in relationships – Giving up important social, occupational or recreational activities because of substance use
Substance Use Disorders – Needing more of the substance to get the effect you want (tolerance) – Development of withdrawal symptoms which can be relieved by taking more of the substance – Using substances again and again, even when it puts the you in danger – Continuing to use, even when a physical or psychological problem could have been caused by or made worse by the substance use
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
DSM-V • Allows clinicians to specify how severe the substance use disorder is, depending on how many symptoms are identified. – mild SUD: 2-3 criteria – moderate SUD: 4-5 criteria – severe SUD: 6 or more criteria
• Removed abuse/dependence distinction • Need 2 criterion (rather than 1 in DSM IV) • Removed caffeine use disorders
Types of Addictions Substance: • • • • •
Alcohol Illicit drugs Prescription drugs Nicotine Food
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
Process: • Eating Disorders • Sex/Relationship • Work • Exercise • Internet • Shopping • Gambling
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What’s different for Women? • Body composition/physiology (Less lean mass, greater ability for drugs stored in fatty tissue to build up to toxic levels in the body) • Personality profile, caregivers (more likely to neglect self and care for others—posing barrier to long term treatment engagement) • Co-occurring conditions: mood, ED, trauma (including domestic violence and sexual trauma)
Addiction in Women • On the rise; according to the Centers for Disease Control and Prevention: – 42 women across the United States die from drug overdose each day – Drugs have killed more women since 2007 than car accidents
• Fastest growing segment of substance use disorders in the U.S.
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
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Why Women? • Pressure to do it all, be it all (caretakers at home and work) • “Cosmetic pharmacology” and image management • Calming effects of alcohol and drugs • Pain relieving properties of prescription narcotics (fibromyalgia, migraines more common in women) • Appetite suppression and energy boost of prescriptions stimulants.
Women--Physiology • Women: – progress in the disease more quickly than men, with lower total amounts of substance over less time than men – Greater sensitivity to effects of drugs due to lower body mass – Metabolize alcohol less efficiently than men because bodies contains less water and more fatty tissue
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
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Effect on Children • Adults whose parents had an alcohol or drug addiction had 69% greater odds of having depression (OR = 1.69; 95% CI, 1.25-2.28) compared with peers with non-addicted parents • This effect remains when controlling for gender, the influences of adverse childhood experiences, adult health behaviors, adult socioeconomic status, and other life stressors. • Children of those with substance use disorders are at greater risk of developing addiction and eating disorders (including BED)
Prevalence • 17.6 million American adults meet criteria for an alcohol use disorder • Approximately 4.2 million meet criteria for a drug use disorder. • 19.4 million persons meet criteria for a substance use disorder according to results from NESARC • Co-occurring: 19.2 million adults have concurrent mood disorders and 23 million have concurrent anxiety disorders • 20 percent of persons with a current substance use disorder experience a mood or anxiety disorder within the same time period. And vice versa.
2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) reported in Archives of General Psychiatry, Volume 61, August 2004.
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Cost of Addiction • Excessive alcohol consumption, mainly binge drinking, cost each state a median of $2.9 billion in 2006, according to an Aug. 13, 2013, study released by the Centers for Disease Control and Prevention. • Costs include: days lost of work, medical care, accident coverage, ER visits
Prescription Drug Misuse • This class of drugs is broadly described as those targeting the central nervous system, including drugs used to treat psychiatric disorders (NSDUH, 2010). • The medications most commonly abused are: • • • •
Pain relievers - 5.1 million Tranquilizers - 2.2 million Stimulants - 1.1 million Sedatives - 0.4 million
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
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Prescription Drug Misuse • In 2010, approximately 7.0 million persons were current users of psychotherapeutic drugs taken non-medically (2.7 % of the U.S. population). • Among adolescents, prescription and overthe-counter medications account for most of the commonly abused illicit drugs by high school seniors (see next slide). • Nearly 1 in 12 high school seniors reported nonmedical use of Vicodin; • 1 in 20 reported abuse of OxyContin.
Prescription Drugs for Women • Legal, doctor prescribed, therefore safe • Accessible – Reported in 2008, approx. 15,000 deaths were attributed to prescription pain killers – Perceive legal meds as legitimate – 85% of websites offering controlled prescription drugs do not require a prescription
• • • •
Less stigma than street drugs Ignorant doctors (little addiction training) “Dirty” doctors/pill mills Ability to “doctor shop”
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
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Treatment • Prevention • Screening • Medical and Psychiatric Assessment • Gender-specific treatment • Integrated Care with expertise to treat co-occurring mood disorders, ED and/or trauma • Family involvement (including children)
Obstacles for Women to Seek Help • Shame, guilt, embarrassment • Male-dominated treatment groups and/or approaches • Resistant to enter tx – mothers, if addiction becomes public, fear that their children may be taken from them – household will not function – lack of childcare – no longer perfect, “failure”
• Minimize the severity of the prescription medication misuse
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Treatment for Addiction and Underlying Issues • Levels of care: outpatient, intensive outpatient, transitional living, partial hospitalization, residential treatment and inpatient • Medical detox: CIWA/COWS, scheduled vs prn meds • Identify/treat co-occurring medical and psychiatric conditions • Gender specific programming or treatment
Treatment for Addiction and Underlying Issues • Treatment engagement • Education (for patient and family), including understanding insurance coverage • Ongoing medication management • Individual, group and family therapies (CBT, IPT, DBT) • 12 step-facilitation • Recovery coaching • Aftercare monitoring
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Co-occurring Conditions • Identify and aggressively treat • Integrated treatment models yield best outcomes • For women: mood disorders, PTSD, and eating disorders commonly co-occur with SUD • Other addictive disorders common in women with SUD: self-injury, relationship addiction, disordered eating, exercise addiction, shopping/spending, gambling, work • ALWAYS assess for domestic violence in women
Barriers to Recovery • Unidentified or under-treated co-occurring disorders (mood disorders, PTSD, eating disorders) • Limited access to gender specific treatment • Failure to include children and family in treatment • Episodic care versus chronic disease management • Limited interpersonal effectiveness skills (DBT) • Limited affect tolerance/regulation skills (DBT)
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Non-addictive Meds: Anxiety • Gabapentin (Neurontin) • Atypical antipsychotics (Seroquel, Geodon) • Buspirone, a mild tranquilizer, can be prescribed for patients who have addiction and generalized anxiety disorder (GAD) • Beta Blockers (propranolol and atenolol) • Antidepressants (SSRIs and SNRIs)
Non-Addictive Meds: Insomnia • Trazadone • Melatonin • Some antidepressants if co-occurring depression (example Remeron) • Some atypical antipsychotics if cooccurring condition warranting their use (example Seroquel, Zyprexa, Risperdal)
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Non-Addictive Meds: ADHD – Wellbutrin – Intuniv • initially used for lowering blood pressure and has recently become more fashionable for treating ADHD • pretty much the opposite of the stimulants, which raise blood pressure and stimulate the body.
– Strattera, used to be “the only non-stimulant treatment approved for ADHD” until Intuniv came onto the market in 2009
Pain management • Non-medication strategies: neurofeedback, acupuncture, meditation, biofeedback, massage • Non-addictive pain meds: gabapentin, Cymbalta, high-dose ibuprofen or acetaminophen, Toradol • Use with caution narcotic pain meds when indicated, with a lot of support (surgery, major physical injury)
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Harm Reduction vs. Abstinence • Importance of matching patient characteristics to treatment approach • Harm reduction is divisive among treatment professionals and 12 step recovery communities alike • Evidence base indicates effectiveness of medication-assisted treatment: naltrexone, acamprosate, buprenorphine, methadone
Relapse Risk in Women • Relationships: women leave treatment prematurely many times to take care of other people (spouses, boyfriend/girlfriend, children, other family members) • Unaddressed or undertreated co-occurring disorders: mood, ED, PTSD common • Taking care of self and recovery needs (attending meetings, therapy, etc) falls behind other obligations.
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Outcome/Assessment Tools • Addiction Severity Index (ASI): outcome measurement tool used to assess resident’s treatment needs • Standardized instrument that has good reliability and validity • Can be used to collect information for comparison at different points in time
Assessment Tools • Tools can be used for assessment of cooccurring depression, anxiety, eating disorders: – Beck Depression Inventory (BDI) – Beck Anxiety Inventory (BAI) – Health Related Quality of Life (HRQOL) – Eating Disorder Inventory-3 (EDI-3) – Eating disorder quality of life scale (EDQOL)
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
March 4, 2015
Practical Recovery Tools • Community support groups: – 12 step meetings (AA, NA, OA, Alanon, SLAA, DA, Dual Diagnosis meetings) – Online support groups (recovery-oriented communities, chat rooms, online meetings, coaching) – Domestic violence support groups – Church groups – NAMI
• Literature: educational, inspirational recovery stories
Maddie’s Treatment Course • Inpatient for ED at age 15 (weight 75#, height 5’5”) • Residential for CD: 2000, and 3 more times between 2012-2013 • Residential for dual diagnosis: TK Oct. 2013-Jan. 2014, TK Feb. 2014 • Multiple inpatient stays for detox and also SI, most recent inpatient detox for Suboxone April, 2014 • PHP/IOP for CD: Jan.-Feb. 2014, relapsed on Valium and began abusing Lyrica; May-June 2014, relapsed on Lyrica (reported “I thought it would help with my ED and anxiety.”)
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
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Next Steps • After completing 21day PHP program for Lyrica use disorder, return to sober residence and IOP • Integrate nutrition therapy weekly • Eating disorder therapist twice per week • Ongoing AA participation, OA participation (and Alanon at some point) • Intensive and long-term treatment by addiction, ED and co-occurring specialists • Active medication management by psychiatrist with addiction and ED expertise: Propranolol 20mg tid, Topamax 50 mg bid, Thorazine 25mg qid, Trazadone 100mg qhs
by serving with uncompromising care, relentless compassion and an unconditional joyful spirit while helping our residents help themselves in their recovery
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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Timberline Knolls Webinar
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THANK YOU FOR JOINING US
Dr. Kim Dennis
[email protected]
A residential treatment center located on 43 beautiful acres just outside Chicago, offering a nurturing environment of recovery for women ages 12 and older struggling to overcome eating disorders, substance abuse, mood disorders, trauma and cooccurring disorders. www.timberlineknolls.com
Timberline Knolls Residential Treatment Center 40 Timberline Drive | Lemont, IL 60439 877.257.9611 | timberlineknolls.com
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1.877.257.9611
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