CAPTASA January 2008
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Transcript of CAPTASA January 2008
CAPTASA January
2008
96-Hour AssessmentsThe 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 Addiction Medicine Evaluation Collateral Data Therapeutic Community
Internal Medicine Evaluation
History Gout Peptic Ulcer Disease / Gastritis/ Esophagitis Hepatitis C Pancreatitis Atrial Fibrillation Seizures Sleep Disturbances
Internal Medicine Evaluation
Physical
Hypertension Tachycardia Tremor Hepatomegaly Spider Angiomata
Palmar Erythema Needle Marks Rosacea Peripheral
Neuropathy
Internal Medicine Evaluation
Transaminitis (i.e îSGOT, SGPT, GGT) Hyperlipidemia Macrocytosis Carbohydrate-Deficient Transferrin Drug Screening
Urine Drug Screening ETG Saliva Testing Hair Testing
Labs
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
Neuropsychiatric Test Findings
A, B & C…A. Split between verbal & performance IQ
> 10 points Usually seen with alcohol,
benzodiazepines, polydrug Impaired visual spatial functions &
visual perceptual speed
Neuropsychiatric Test Findings
B. Impairments typically seen in the other tests when addressing patients with a history of
Alcohol Sedative hypnotic, or Polydrug abuse
Neuropsychiatric Test Findings
C. Impairments not typically seen in abusers of
Opiates Amphetamines, or Hallucinogens
Psychological Testing
Minnesota Multiphasic Personality Inventory –2 (MMPI-2)
Million Clinical Multiaxial Inventory III (MCMI-III)
Psychological Findings
Scales to address addiction and addiction potential document emotional and personality variables which may affect treatment.
Psychiatric Evaluation
Part of the addiction assessment Dual Diagnoses Issues…
Depressive Disorders Anxiety Disorders ADD/ADHD Bipolar Disorders Axis II Diagnosis
Important Issues Addressed in the Psychiatric Evaluation
Is the psychiatric diagnosis the primary issue?
Medication Management Issues
Appropriate Level of Care
Addiction Medicine Evaluation
DSM IV Criteria
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
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.
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.
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
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
Additional Assessments If Indicated
Pain Evaluation
Sexual Boundaries Evaluation
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)
96-Hour Assessments
Advantages Thorough evaluation done in 4 days Therapeutic Community Teamwork vs. Splitting
Disadvantages Travel Cost ($5,000) Perceived conflict of interest
0
100
200
300
400
500
600
1998 1999 2000 2001 2002 2003 2004 Total
96 Hr Assmt. Tx Rec. Tx Acpt.
Assessment Recommendations1998-2004
Assessment Recommendations1998-2004
Totals96-Hour Assessments 597
Treatment Recommended 333
Percent Tx. Recommended 56%
Treatment Accepted 218
Percent Tx. Accepted 65%
Treatment not recommended 264
Percent Tx. not recommended 44%
Assessment Recommendations1998-2001
1998 1999 2000 2001
96-Hour Assessments 78 55 74 100
Tx Recommended 47 29 37 60
% Tx recommended 60% 53% 60% 53%
Tx Accepted 27 14 24 44
% Tx Accepted 57% 48% 65% 73%
Tx not recommended 31 26 37 40
% Tx not recommended 40% 47% 50% 40%
Assessment Recommendations2002-2004
2002 2003 2004
96-Hour Assessments 78 55 74
Tx Recommended 47 29 37
% Tx recommended 60% 53% 60%
Tx Accepted 27 14 24
% Tx Accepted 57% 48% 65%
Tx not recommended 31 26 37
% Tx not recommended 40% 47% 50%
Talbott Recovery CampusReview of Assessments
1998-2004 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
Occupation 499 patients (83.7%) – Health Professionals
Health Prof. Number Percent
MD 324 64.9%
DDS 72 14.4%
RN 23 4.6%
DO 23 4.6%
RPh 16 3.2%
Med. Student 9 1.8%
RN/PA 6 1.2%
Veterinarian 5 1.0%
LPN 5 1.0%
Medical Tech 3 0.6%
Health Prof. Number Percent
Chiropractor 2 0.4%
Psychologist 2 0.4%
Physician’s Asst. 2 0.4%
Health Admin 2 0.4%
Social Worker 1 0.2%
Podiatrist 1 0.2%
Nurse Practitioner
1 0.2%
Naturopath 1 0.2%
Paramedic 1 0.2%
Occupation (cont’d)
Specialty Number Percent
Gen/Family Practice 70 21.6%
Internal Medicine 59 18.2%
Anesthesia 55 17.0%
Emergency Medicine 23 7.1%
OB/GYN 15 4.6%
Pediatrics 14 4.3%
Psychiatry 14 4.3%
Radiology/Oncology 10 3.1%
Surgery, General 9 2.8%
Surgery, Neurological 9 2.8%
MD Specialty
Specialty Number Percent
Surgery, Plastic 7 2.2%
Surgery, Urology 7 2.2%
Pathology 4 1.2%
Surgery, Cardiothoracic 4 1.2%
Surgery, ENT 4 1.2%
Neurology 3 0.9%
Pain 3 0.9%
Surgery, Ophthalmologic 3 0.9%
Neurology 3 0.9%
Occupational 2 0.6%
MD Specialty (cont’d)
Specialty Number Percent
Surgery, Orthopedic 2 0.6%
Anesthesiology 1 0.3%
Dermatology 1 0.3%
Physical Medicine 1 0.3%
Surgery, Pediatric 1 0.3%
MD Specialty (cont’d)
Non-Health Professionals
98 Patients (16.3%) 10 attorneys 32 pilot/flight attendants
Referral SourcesState Medical Boards 44%
PHP, PRN, PAP 21%
Employer 8%
Hospital Authority 8%
Partners 4%
Self 4%
For return to work 4%
Family 3%
Attorney 3%
Wife, Friend 2%
Military 1%
Medical School 1%
Final Diagnoses Categories
Diagnoses Categories Number Percent
Alcohol Abuse/Dep. 144 34.8%
Opiate Abuse/Dep. 86 20.8%
No Final Diagnosis 55 13.3%
Polysub.Abuse/Dep. 20 4.8%
Depressive Disorder 14 3.4%
Major Depression 14 3.4%
Cocaine Abuse/Dep. 8 1.9%
Partner Relationship 8 1.9%
Cannabis Abuse/Dep. 7 1.7%
Bipolar Disorder 7 1.7%
Cognitive Disorder 7 1.7%
Final Diagnoses Categories (cont’d)
Diagnoses Categories Number Percent
Amphet. Abuse/Dep. 6 1.4%
Occupational Problems 6 1.4%
Sed-hypnotic Abuse 4 1.0%
Misc. 5 1.2%
Dysthymia 4 1.0%
Panic Disorder 4 1.0%
Benzo. Abuse/Dep. 3 0.7%
Pathologic Gambling 3 0.7%
Sexual Disorder 3 0.7%
Nitrous Oxide Abuse 3 0.7%
Pain Disorder 2 0.5%
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.
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
Drugs of Abuse/Dependence
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)
Dual Diagnosis
66% of patients diagnosed with Abuse/Dependence have one or more coexisting disorders in diagnostic profile
Dual Diagnosis (Axis 1)
Major Depression/Depressive Disorder NOS
44%
Addiction to other drug families 43%
Dysthymia/Bipolar Disorder 22%
Cognitive Disorders/Inefficiency 6%
Axis II Diagnostic Patterns
47% of all assessment patients were diagnosed with abnormal personality characteristics.
Axis II Traits/Features
Traits/Features Number %-Axis II
Narcissistic 54 28%
Compulsive 32 17%
Histrionic 23 12%
Avoidant 19 9%
Ob-Compulsive 14 7%
Dependent 8 4%
Passive Aggressive 1 0.5%
Axis II Traits/Features (cont’d)
Traits/Features Number %-Axis II
Antisocial 5 2.6%
Schizoid 3 1.6%
Cluster B 4 2.1%
Obsessive 3 1.6%
Borderline 2 1.0%
Self Defeating 1 0.5%
Personality Disorder 24 6%
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