|
Physicians Corner
|
|
David Smith, MD, FASAM
Chair, Addiction Medicine Newport Academy
 |
 |
| David Smith, MD |
|
Benzodiazepines are part of a broad drug class called sedatives hypnotics and include a broad range of widely used medications from Librium (chlordiazapoxide) for anxiety, Halcion (Triazolam) for sleep, to Midazolam (Versed) for anesthesia depending on the potency and duration of action of the chemical compound. There has been a dramatic rise in prescription drug abuse in adolescents involving opioids and benzodiazepines as part of a poly-drug abuse pattern.
The development of sedative hypnotic abuse and dependence in adolescents poses a new challenge to adolescent addiction treatment programs not familiar with the potential serious medical consequences. Sedative-hypnotics include a chemically diverse group of medications primarily prescribed for treatment of anxiety, panic disorders, sleep disturbances and seizure disorders. They may be misused, and their use can result in development of a substance use disorder, abuse or dependence with physiological dependence. Inadequately treated, withdrawal of sedative-hypnotics may be life-threatening. Considerations of sedative-hypnotic use disorders should reflect a sensible balance between their medical uses, and abuse and dependence.
Establishing whether or not the dysfunctional behavior is the “result” of drug use is extremely important. The patient may need to be observed medication-free to determine whether dysfunction is “caused” by drug use. The patient, the patient’s family members and the treating psychiatrist may disagree about what is causing symptoms or behavioral dysfunction. Likewise, the underlying motivation for “drug-seeking” behavior may vary. For example, a patient whose panic attacks are ameliorated by a medication may exhibit what may be interpreted as drug-seeking behavior if access to the medication is threatened.
Drug dependence may arise as an inadvertent consequence of medical treatment or through patient’s self abuse of sedative-hypnotics. The prevalence of abuse of a particular sedative-hypnotic is to some extent a reflection of its accessibility through medical channels.
Most abuse of benzodiazepines is in the context of a poly-drug use pattern in which they are taken in combination with other primary intoxicants, such as alcohol or heroin, to intensify the desired subjective effects.
Addicts episodic attempts to stop using heroin by self-medicating opiate withdrawal symptoms with sedative-hypnotics without entering drug abuse treatment rarely results in opiate abstinence and may result in the secondary development of sedative-hypnotic dependence.
Addicts may also use sedative-hypnotics to reduce unpleasant side effects of stimulants, e.g., cocaine or methamphetamine. Impairment of judgment and memory produced by the sedative-hypnotic in combination with wakefulness or a stimulant may result in unpredictable behavior.
For recreational purposes, benzodiazepines are rarely used alone. More commonly, they are used in combination with an opiate, alcohol, or some combination of drugs. Sedative-hypnotics can produce tolerance and physiological dependence.
The withdrawal syndrome arising from the discontinuation of short-acting sedative-hypnotics is similar to that from stopping or cutting down on the use of alcohol. Signs and symptoms of sedative-hypnotic withdrawal include anxiety, tremors, nightmares, insomnia, anorexia, nausea, vomiting, postural hypotension, seizures, delirium, and hyperpyrexia. The syndrome is qualitatively similar for all sedative-hypnotics: however, the time course of symptoms depends on the particular drug. With short acting sedative-hypnotics withdrawal symptoms typically begin 12-24 hours after the last dose and peak in intensity between 24 and 72 hours. With long-acting drugs withdrawal signs and symptoms peak on the fifth to eighth day.
The withdrawal delirium may include confusion, visual and auditory hallucinations. The delirium generally follows a period of insomnia. Some patients may have only delirium; others only seizures; and some may have both delirium and convulsions.
Some people who have taken benzodiazepines in therapeutic doses for months to years can abruptly discontinue the drug without developing withdrawal symptoms. Others develop symptoms ranging from mild to severe when the benzodiazepine is discontinued.
Characteristically, patients tolerate a gradual tapering of the benzodiazepine until they are at 10- 20% of their peak dose. Further reductions in benzodiazepine dose then cause patients to become increasingly symptomatic. In addiction medicine literature, the low-dose withdrawal may be called therapeutic-dose withdrawal, normal-dose withdrawal, or benzodiazepine discontinuation syndrome. They symptoms can ultimately be categorized as symptom reemergence, symptom rebound, or a prolonged withdrawal syndrome.
Protracted benzodiazepine withdrawal may consist of relatively mild withdrawal symptoms such as anxiety, mood instability, and sleep disturbance similar to the protracted withdrawal syndrome described for alcohol and other drugs. In some patients, the protracted withdrawal syndrome from benzodiazepines can be severe and disabling and last many months.
For discontinuation of benzodiazepines that are being used at dosages above those generally prescribed, one pharmacotherapy strategy is to substitute Phenobarbital and stabilization period of 3-7 days, to taper the Phenobarbital 30 mg/day. As discussed next, some patients who take high doses of benzodiazepines, or even therapeutic doses for months to years, may have prolonged withdrawal symptoms.
Three general strategies are used for withdrawing patients from sedative-hypnotics, including benzodiazepines. They first is to use decreasing doses of the agent of dependence. The second is to substitute Phenobarbital or some other long-acting barbiturate for the addicting agent, and gradually withdraw the substitute medication (Smith and Wesson 1970, 1971). The third, used for patients with a dependence on both alcohol and a benzodiazepine, is to substitute a long acting benzodiazepine, such as chlordiazepoxide, and taper it during 1-2 weeks.
The preferred withdrawal strategy depends on the particular benzodiazepine, the involvement of other drugs of dependence, and the clinical setting in which the detoxification program takes place. Psychosocial treatments are those services in addition to the medical management of withdrawal. At settings like Newport Academy, where I serve as Chair of Addiction Medicine, both psychosocial treatments and medical management of symptoms can be adequately addressed. When provided by psychiatrists, psychotherapy may be combined with medical management. Usually, in an inpatient drug abuse treatment setting like Newport Academy, psychosocial services are groups and counseling provided by chemical dependence counselors, who may be in recovery from drug or alcohol dependence. While there are specific types of therapy, such as relapse prevention, motivational enhancement or cognitive behavioral therapy, most counselors use a blend of their own recovery experience, the 12-step recovery, and professional training.
Smith De & Wesson DR “A new method for treatment of Barbiturate Dependence.” JAMA 213 (2) 294-95
Substance Abuse: Sedative, Hypnotic or Anxiolytic Use Disorders; Wesson DR, Smith DE, Ling W, Sabnai S, C 64 Psychiatric, Third Edition.
Newport Academy is proud to share that its’ Chair of Addiction Medicine, David Smith, MD, FASAM, FAACT, will be presented the Annual Award at the American Society of Addiction Medicine (ASAM) during the ASAM awards luncheon on April 17, 2010. This award is given annually for “outstanding contributions to the growth and vitality of the American Society of Addiction Medicine, for thoughtful leadership in the field, and for a deep understanding of the art and science of Addiction Medicine.”
This award will be presented at the annual ASAM conference which is being held in San Francisco, CA April 15-18, 2010. This is an association of physicians dedicated to improving the treatment of alcoholism and other addictions, educating physicians and medical students, promoting research and prevention, and enlightening and informing the medical community and the public about these important issues.
View Article at ASAM Site
|
Staff Spotlight
|
 |
|
| Mika Roux |
|
Mika Roux, MA, IMFT, HHS is a primary therapist at Newport Academy and works extensively with the residents and families. Since joining Newport Academy as a Primary Therapist Mika has been willing to go beyond her job description of providing individual therapy to participating in the family program whenever needed, as well as doing clinical outreach to local area schools, and working with our alumni on their transition to the next level of care. Mika offers the residents and families a calming energy which is often lacking in their chaotic lifestyles. She engages our residents in exploring their spirituality by introducing them to the local meditation gardens or by walking the labyrinth. Mika was also responsible for making the initial contact at Torrey Pines High School which resulted in educational presentations for all the faculty and staff. She is a shining example of the spirit of cooperation and team work. Mika can often be found at Newport Academy in the late hours of the evenings chatting with the girls or on the phone with parents or alum. Newport Academy is blessed to have Mika on our staff and grateful for the contribution she makes every day to our residents and their families. |
 |
|
 |
 |
 |
|
|
|
Newport Academy Events
January 28 – January 30, 2010:
Exhibitor David E. Smith, M.D., FASAM, FAACT. Newport Academy upcoming 2009/2010 conference and event participation. La Jolla, CA, NATSAP.
February 5, 2010: Jeff Fortuna Dr. P.H. Fish Oil & Omega 3 Fatty acids in the Treatment of Psychiatric Syndromes. Medical Grand Rounds at St. Joseph Hospital, Orange, Ca.
April 16, 2010: Jeff Fortuna Dr. P.H. Sugar Addiction & the Sweet Tooth: Genetic Determinants in the Alcoholic Family. Adolescent & Young Adult Treatment Conference, for the US Journal Adolescent & Young Adult Treatment Conference in Las Vegas, Nevada.
April 16, 2010: Jeff Fortuna Dr. P.H. Basic Nutritional Guidelines for Adolescent Patients. Adolescent & Young Adult Treatment Conference, for the US Journal Adolescent & Young Adult Treatment Conference in Las Vegas.
April 17, 2010: Jeff Fortuna Dr. P.H. Street Drug Trends- 2010. Adolescent & Young Adult Treatment Conference, for the US Journal Adoelsecent & Young Adult Treatment Conference in Las Vegas. |
|
|
Mickey K. Troxell, MS, CATC, CEAT II
Owner, CEO – Pegasus ECT, Centaur University
Costa Mesa, California
Equine Therapist, Newport Academy
My passion and love for horses began when I was a young girl, this connection [with horses] began before I was able to speak or walk.
My professional journey working with horses began when I studied Equine Assisted Psychotherapy under Greg Kersten, the Founder of Equine Assisted Psychotherapy. Greg has set the standard in teaching techniques for working with horses to help humans.
The therapeutic value and benefit of working with horses is historically cited as long ago as 460BC in which Hippocrates spoke of [the] “healthy pace of the horse.” |
 |
| Mickey and her horse Boo |
| (EAP) Equine Assisted Psychotherapy is utilized by Pegasus ECT (Experiential Counseling Techniques) in individual and group counseling sessions. In these sessions Certified Therapy Horses are used as significant partners in collaboration with Certified Equine Assisted Therapists / Counselors and Certified Equine Specialists to stimulate growth and development in people who have a desire to grow emotionally, mentally, spiritually and physically. (EAP) Equine Assisted Psychotherapy and (EFT) Equine Facilitated Therapy is client-based therapy that provides hands-on opportunities to experience new solutions, to develop healthy coping skills and [new] tools for effectively realizing and managing internal happiness.
Case Example – Equine Assisted Psychotherapy at Newport Academy, a Gender Specific Adolescent Facility in Orange, CA
A journey to redefine one precious life was guided and nurtured by Levi, a certified therapy horse, who bonded quickly with a young, depressed and withdrawn teenage girl named Suzanne (named changed to protect confidentiality). Levi quickly assessed this young girl’s disposition, her deep-seated need to stay disconnected from him and everyone else. Levi was patient and steadfast.
Suzanne knew that Levi was an abuse survivor, that prior to becoming a therapy horse he had been severely abused by his owners because of this knowledge, she experienced an initial bond or connection, that despite her desire to stay separated, caused her to move closer as she watched Levi interact with her peers. Horses like Levi intuitively know what people need to work on, usually before they do and he patiently works at their pace never intruding on their boundaries, never forcing them farther than they can go. Suzanne, while inclined to stay as removed as possible, found herself drawn to the process, but was terrified of revealing too much of herself. The damaged inner self that she had spent a lifetime building a wall around dictated that she stay a part from rather than a part of, as in all relational experiences since she was abused.
This experiential reasoning caused her to deny the trauma within, as well as her need to connect with others, and, as such, she fabricated even the most trivial occurrences about her life during the initial therapy sessions common amongst abuse survivors. Levi, the consummate professional, met Suzanne where she was at and worked with her at her pace and slowly exposed every detail of her fabrications, the depth of her denial, and her desperate need for recovery for the hurt she had experienced. It was mutual perseverance and stubbornness that brought Suzanne out of her internal prison. The young girl who didn’t want to bond bonded intensely and began her process of recovery through the spirit of the horse. Through Equine Therapy, Suzanne allowed herself to become vulnerable in order to grieve and heal from the debilitating wounds within.
Levi walked with Suzanne out of the dark solitude of a life of abuse into the Light of healing her transformation was awe inspiring her miracle began with a horse named, Levi.
Equine Assisted Psychotherapy addresses a variety of mental health and human developmental needs including behavioral issues, Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD), substance abuse/chemical dependency, eating disorders, depression, anxiety, Autism, communication and relational issues, and has found much success in addressing Post Traumatic Stress Disorder with veterans and others who have witnessed or have been subjected to traumatic events. At Pegasus ECT we work individually and in groups with adolescents, adults, veterans, at-risk youth, and Native Americans. We strive to utilize the latest advances in this field for the continued growth and recovery of our clients.
Utilizing EAP I work with individuals or in groups of 6-8. One of the most thought-provoking and engaging learning experiences for clients is conducted in a group where the clients are placed in two teams and given one instruction to take the horse(s) through a series of exercises, utilizing only a lead and each other within the confines of the corral without verbal communication.
In this exercise clients learn the following: a) how to consciously communicate with one another and the horse(s) non-verbally; b) while there is only one instruction, its limitations are either stifling or liberating, depending upon the individual and collective perceptions of the participants; and, c) the arena, the horse, and the people in it are all part of the same team (collective consciousness) even when divided. This experience is tangible and it resonates in the lives of the participants and is forever branded into their experience it’s all about perspective in and/or out of the corral; in and/or out of disorder, dysfunction or disease; in and/or out of the experiential reasoning that human beings are forever bound to. The experience of Equine Therapy is miraculous and dynamic in its therapeutic value to the individuals who engage in its awesome, healing power.
A former client’s perspective – Equine therapy was a foreign concept to me when I arrived at the stables for the first time. I couldn’t imagine how a horse could supplement the traditional forms of therapy I’d been engaged in throughout my life.
Psychiatrists, counseling, group therapy, etc.I had been searching for something to sort out the roots of my dysfunctional behavior and addiction for years. It was only by chance (or design?) that I ended up working with Mickey and the time I spent with her and the horse impacted me in ways that I couldn’t have anticipated. What I learned about myself and the work I needed to do in a few hours was profound compared to my experience of many months of therapy in past counseling endeavors. The exercises we did and its relevance to my life inspired an awareness and clarity about the road ahead of me, the process of recovery, and developed within me an amazing willingness that I had never felt before.
Horses have an ability to read people and their body language which works in conjunction with equine therapists who assess the client’s personality/needs/issues based on the horse’s responses to [the client's] energy, movement, and non-verbal cues. Mickey’s translation of my behavior and the decision-making process I engage in (in and out of the corral), became a microcosm for my life. There are unhealthy or dysfunctional aspects of my personality that dictate how I behave in situations, these responses are so ingrained in my psyche that I have, in the past, chosen to be oblivious to because change seemed like such a monumental, arduous task.
Engaging with a horse, who is by nature intuitive and responsive, provided me with an interactive ability to view and assess my interactions with people. For example, there are things I do on a daily basis during introductions and engagements with people that I had never recognized as choices I make – watching the horse mirror my energy coupled with Mickey’s observation and insight about my responses, forced me to acknowledge behavioral patterns that were adversely affecting my life main example: shutting down emotionally, mentally, psychologically, and spiritually when I feel intimidated. It is difficult to deny that you act a certain way or to manipulate your interpretation of your behavior after it has been witnessed and discussed in the forum of change that the corral became for me. Mickey was able to describe what she saw and use the experience with the horse as a metaphor for daily struggles I experienced.
Equine therapy is an experiential alternative to interactive group therapy. It is an opportunity to recognize and practice different ways of responding to situations without the fear of judgment that interferes with growth. In addition to building my awareness about what was limiting my success in different areas of my life (i.e., that my perceptions are often skewed; that reservations limit my options; and, that only by confronting my fears can I acquire a rational outlook on life and develop effective, healthy coping skills to live life on life’s terms), I developed a new way to approach situations that used to baffle me. The equine therapy exercises that I participated in strengthened my confidence and gave me a newfound willingness to begin working on overcoming these limitations.
Mickey says that people often react to people and places the way they do because of a perceived lack of options. I, like many people, tend to confine myself between the proverbial rock and a hard place because I don’t allow myself to see that I have multiple choices in most situations.
Through the process of equine therapy and the introspection it spurred within me, I learned that I have a tendency to focus on what I can’t do, rather than what I can. The enormity of this realization freed me from a deeply-rooted internal prison I didn’t even know I was in. This “ah ha!” moment, this perceptual shift, afforded me a life-altering freedom I am grateful for.
Equine therapy addressed my perceived limitations based on past experiential reasoning more directly and dramatically than anything I had or have ever experienced. I learned unequivocally that most of my fears are irrational and that the most effective way to overcome fear is to walk through it not around it, over it, or under it through it. By acknowledging this realization on a daily basis and moving through my fears, my self-efficacy is developing and increasing.
Now this may seem like common sense to many people but it isn’t to someone like me. This simple exercise with the horse which had an outcome I couldn’t foresee provided tangible evidence of my faulty thinking and how it prevents me from taking risks on a daily basis. Most importantly, it gave me the faith I desperately needed to trust that, contrary to my beliefs, outcomes just may turn out to be positive, and that [taking] risks is the only way to experience this faith and the potential of changed outcomes. Today I approach situations I used to view as obstacles as opportunities to overcome my fears and grow.
Let the Spirit of the
Horse lift you up!
|
|
|
 |
|
|
Loading ...
