CAPTASA January 2008

45
CAPTASA January 2008 96-Hour Assessments The New Intervention Tool Michael Wilkerson, MD Medical Director Bradford Health Services

description

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 - PowerPoint PPT Presentation

Transcript of CAPTASA January 2008

Page 1: CAPTASA  January  2008

CAPTASA January

2008

96-Hour AssessmentsThe New Intervention Tool

Michael Wilkerson, MD

Medical Director

Bradford Health Services

Page 2: CAPTASA  January  2008

96-Hour Assessment Components

Internal Medicine Evaluation Laboratory Work Psychological & Neuropsychiatric Testing Psychiatric Evaluation Addiction Medicine Evaluation Collateral Data Therapeutic Community

Page 3: CAPTASA  January  2008

Internal Medicine Evaluation

History Gout Peptic Ulcer Disease / Gastritis/ Esophagitis Hepatitis C Pancreatitis Atrial Fibrillation Seizures Sleep Disturbances

Page 4: CAPTASA  January  2008

Internal Medicine Evaluation

Physical

Hypertension Tachycardia Tremor Hepatomegaly Spider Angiomata

Palmar Erythema Needle Marks Rosacea Peripheral

Neuropathy

Page 5: CAPTASA  January  2008

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

Page 6: CAPTASA  January  2008

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

Page 7: CAPTASA  January  2008

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

Page 8: CAPTASA  January  2008

Neuropsychiatric Test Findings

B. Impairments typically seen in the other tests when addressing patients with a history of

Alcohol Sedative hypnotic, or Polydrug abuse

Page 9: CAPTASA  January  2008

Neuropsychiatric Test Findings

C. Impairments not typically seen in abusers of

Opiates Amphetamines, or Hallucinogens

Page 10: CAPTASA  January  2008

Psychological Testing

Minnesota Multiphasic Personality Inventory –2 (MMPI-2)

Million Clinical Multiaxial Inventory III (MCMI-III)

Page 11: CAPTASA  January  2008

Psychological Findings

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

Page 12: CAPTASA  January  2008

Psychiatric Evaluation

Part of the addiction assessment Dual Diagnoses Issues…

Depressive Disorders Anxiety Disorders ADD/ADHD Bipolar Disorders Axis II Diagnosis

Page 13: CAPTASA  January  2008

Important Issues Addressed in the Psychiatric Evaluation

Is the psychiatric diagnosis the primary issue?

Medication Management Issues

Appropriate Level of Care

Page 14: CAPTASA  January  2008

Addiction Medicine Evaluation

DSM IV Criteria

Page 15: CAPTASA  January  2008

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

Page 16: CAPTASA  January  2008

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.

Page 17: CAPTASA  January  2008

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.

Page 18: CAPTASA  January  2008

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

Page 19: CAPTASA  January  2008

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

Page 20: CAPTASA  January  2008

Additional Assessments If Indicated

Pain Evaluation

Sexual Boundaries Evaluation

Page 21: CAPTASA  January  2008

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)

Page 22: CAPTASA  January  2008

96-Hour Assessments

Advantages Thorough evaluation done in 4 days Therapeutic Community Teamwork vs. Splitting

Disadvantages Travel Cost ($5,000) Perceived conflict of interest

Page 23: CAPTASA  January  2008

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

Page 24: CAPTASA  January  2008

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%

Page 25: CAPTASA  January  2008

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%

Page 26: CAPTASA  January  2008

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%

Page 27: CAPTASA  January  2008

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

Page 28: CAPTASA  January  2008

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%

Page 29: CAPTASA  January  2008

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)

Page 30: CAPTASA  January  2008

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

Page 31: CAPTASA  January  2008

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)

Page 32: CAPTASA  January  2008

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)

Page 33: CAPTASA  January  2008

Non-Health Professionals

98 Patients (16.3%) 10 attorneys 32 pilot/flight attendants

Page 34: CAPTASA  January  2008

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%

Page 35: CAPTASA  January  2008

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%

Page 36: CAPTASA  January  2008

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%

Page 37: CAPTASA  January  2008

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.

Page 38: CAPTASA  January  2008

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

Page 39: CAPTASA  January  2008

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)

Page 40: CAPTASA  January  2008

Dual Diagnosis

66% of patients diagnosed with Abuse/Dependence have one or more coexisting disorders in diagnostic profile

Page 41: CAPTASA  January  2008

Dual Diagnosis (Axis 1)

Major Depression/Depressive Disorder NOS

44%

Addiction to other drug families 43%

Dysthymia/Bipolar Disorder 22%

Cognitive Disorders/Inefficiency 6%

Page 42: CAPTASA  January  2008

Axis II Diagnostic Patterns

47% of all assessment patients were diagnosed with abnormal personality characteristics.

Page 43: CAPTASA  January  2008

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%

Page 44: CAPTASA  January  2008

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%

Page 45: CAPTASA  January  2008

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