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CAPTASA January 2008

CAPTASA January 2008. 96-Hour Assessments The New Intervention Tool Michael Wilkerson, MD Medical Director Bradford Health Services. 96-Hour Assessment Components. Internal Medicine Evaluation Laboratory Work Psychological & Neuropsychiatric Testing Psychiatric Evaluation

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CAPTASA January 2008

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  1. CAPTASA January 2008 96-Hour Assessments The New Intervention Tool Michael Wilkerson, MD Medical Director Bradford Health Services

  2. 96-Hour Assessment Components • Internal Medicine Evaluation • Laboratory Work • Psychological & Neuropsychiatric Testing • Psychiatric Evaluation • Addiction Medicine Evaluation • Collateral Data • Therapeutic Community

  3. Internal Medicine Evaluation History • Gout • Peptic Ulcer Disease / Gastritis/ Esophagitis • Hepatitis C • Pancreatitis • Atrial Fibrillation • Seizures • Sleep Disturbances

  4. Internal Medicine Evaluation Physical • Hypertension • Tachycardia • Tremor • Hepatomegaly • Spider Angiomata • Palmar Erythema • Needle Marks • Rosacea • Peripheral Neuropathy

  5. Internal Medicine Evaluation Labs • Transaminitis (i.e îSGOT, SGPT, GGT) • Hyperlipidemia • Macrocytosis • Carbohydrate-Deficient Transferrin • Drug Screening • Urine Drug Screening • ETG • Saliva Testing • Hair Testing

  6. Neuropsychiatric Testing • Wechesler Adult Intelligence Scale • Memory Assessment Scale • Halstead Reitan Neuropsychological Tests • Tactual Performance Test • Finger Tapping Test • Reitan Indiana Aphasia Screening Test • Trailmaking Test

  7. Neuropsychiatric Test FindingsA, B & C… • Split between verbal & performance IQ • > 10 points • Usually seen with alcohol, benzodiazepines, polydrug • Impaired visual spatial functions & visual perceptual speed

  8. Neuropsychiatric Test Findings • Impairments typically seen in the other tests when addressing patients with a history of • Alcohol • Sedative hypnotic, or • Polydrug abuse

  9. Neuropsychiatric Test Findings C.Impairments not typically seen in abusers of • Opiates • Amphetamines, or • Hallucinogens

  10. Psychological Testing • Minnesota Multiphasic Personality Inventory –2 (MMPI-2) • Million Clinical Multiaxial Inventory III (MCMI-III)

  11. Psychological Findings Scales to address addiction and addiction potential document emotional and personality variables which may affect treatment.

  12. Psychiatric Evaluation • Part of the addiction assessment • Dual Diagnoses Issues… • Depressive Disorders • Anxiety Disorders • ADD/ADHD • Bipolar Disorders • Axis II Diagnosis

  13. Important Issues Addressed in the Psychiatric Evaluation • Is the psychiatric diagnosis the primary issue? • Medication Management Issues • Appropriate Level of Care

  14. Addiction Medicine Evaluation DSM IV Criteria

  15. Generic Criteria for Substance Dependence The Patient’s maladaptive pattern of substance use leads to clinically important distress or impairment shown in a single 12-month period by 3 more of the following: • Tolerance, shown by either of: • Markedly increased intake of the substance is needed to achieve the same effect or • With continued use, the same amount of the substance has markedly less effect • Withdrawal, shown by either of: • The substance’s characteristic withdrawal syndrome or • The substance (or one closely related) is used to avoid or relieve withdrawal symptoms

  16. Generic Criteria for Substance Dependencecontinued… • The amount of duration of use is often greater than intended. • The patient repeatedly tries without success to control or reduce substance use. • The patient spends much time using the substance, recovering from its effects or trying to obtain it. • The patient reduces or abandons important social, occupational or recreational activities because of use. • The patient continues to use the substance, despite knowing that it has probably caused physical or psychological problems.

  17. Generic Criteria for Substance Abuse • The patient’s maladaptive substance use pattern causes clinically important distress or impairment in a single 12-month period by 1 or more of the following: • Because of repeated use, the patient fails to carry out major obligations at work or at home. • The patient uses substances even when it is physically dangerous. • The patient repeatedly has legal problems from substance use. • Despite knowing that it has caused or worsened social or interpersonal problems, the patient continues to use the substance. • For this class of substance, the patient has never fulfilled criteria for substance dependence.

  18. Collateral Data • Assessment Coordinator Directs • Full Time Position • Collects information from family, friends and colleagues • Coordinator meets with individual daily • Must be able to ask the “right questions” • Helps the individual reprocess any new information

  19. Therapeutic Community • Housed in apartment complex with other peers who are in treatment • Attend groups and 12-Step meetings • Attend 1st Step presentations • Can “mirror image” off others in the community

  20. Additional Assessments If Indicated • Pain Evaluation • Sexual Boundaries Evaluation

  21. Indications for a 96-Hour Assessment • Unclear Diagnosis • Determine Level of Care Needed • Secondary Intervention • Confirm Non-diagnosis • Fit to Return to Duty • Relapse Issues (not only use but behavior)

  22. 96-Hour Assessments Advantages • Thorough evaluation done in 4 days • Therapeutic Community • Teamwork vs. Splitting Disadvantages • Travel • Cost ($5,000) • Perceived conflict of interest

  23. Assessment Recommendations1998-2004

  24. Assessment Recommendations1998-2004

  25. Assessment Recommendations1998-2001

  26. Assessment Recommendations2002-2004

  27. Talbott Recovery CampusReview of Assessments1998-2004 • Age and Sex • The average age of 597 patients assessed from 1998 through 2004 was 44.9 years with a range from 22 years to 84 years. The average age didn’t vary from year to year. • 494 patients (82.5%) were male with the average age of 45.9 years • 103 patients (17.5%) were female with the average age of 40.5 years

  28. Occupation 499 patients (83.7%) – Health Professionals

  29. Occupation (cont’d)

  30. MD Specialty

  31. MD Specialty (cont’d)

  32. MD Specialty (cont’d)

  33. Non-Health Professionals • 98 Patients (16.3%) • 10 attorneys • 32 pilot/flight attendants

  34. Referral Sources

  35. Final Diagnoses Categories

  36. Final Diagnoses Categories (cont’d)

  37. Drugs of Abuse/Dependence • Alcohol was first drug of choice (46%) • 61 patients with other diagnoses also consumed alcohol making it significant in 63% of all assessments • Opiates was drug of choice in 41% of patients.

  38. Drugs of Abuse/Dependence • Hydrocodone was opiate of choice in 58% of Opiate Abuse/Dependence cases. • Oxycodone was drug of choice in 17% • Fentanyl was drug of choice in 17% • Other drugs were propoxyphene, codeine, meperidine, hydromorphone and morphine. • Analgesics butophanol (Stadol) and tramadol (Ultram) were reported in a few cases-usually in conjunction with other drugs

  39. Drugs of Abuse/Dependence • Amphetamines was first drug of choice in 9 cases (methamphetamine and prescription amphetamines) • Second and third choice drugs in amphetamine addicts were alcohol, benzodiazepines and opiates • Butalbital was the principle drug of choice in patients reporting sedative-hypnotic use. • Diazepam, alprazolam, zolpidem and lorazepam were principal benzodiazepine drugs of choice. • 56% of patients reported use of nicotine-containing products (63% of patients admitted for regular treatment report use of nicotine-containing products)

  40. Dual Diagnosis • 66% of patients diagnosed with Abuse/Dependence have one or more coexisting disorders in diagnostic profile

  41. Dual Diagnosis (Axis 1)

  42. Axis II Diagnostic Patterns • 47% of all assessment patients were diagnosed with abnormal personality characteristics.

  43. Axis II Traits/Features

  44. Axis II Traits/Features (cont’d)

  45. Talbott Recovery CampusMichael Wilkerson, MD, Medical Director 1-800-445-4232 www.talbottcampus.com 5448 Yorktowne Drive Atlanta, GA 30349 Lisa Cottrell,MA, LAPC 96-Hour Coordinator

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