The Psychiatric clinics of North America
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Leukoencephalopathy is a syndrome of neurologic deficits, including alteration of mental status, caused by pathologic changes in the cerebral white matter. The term, toxic leukoencephalopathy, encompasses a wide variety of exposures and clinical presentations. The diagnosis in these Frontiers in Clinical Neurotoxicology syndromes is made by careful attention to the history, clinical features, and radiologic findings. This article details three of the best-defined toxic leukoencephalopathies: delayed posthypoxic leukoencephalopathy, including delayed neurologic sequelae after carbon monoxide poisoning; heroin inhalation leukoencephalopathy; and posterior reversible encephalopathy syndrome.
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Psychiatr. Clin. North Am. · Jun 2012
Training the next generation of providers in addiction medicine.
Within the United States there exists a profound discrepancy between the significant public health problem of substance abuse and the access to treatment for addicted individuals. Part of the insufficient access to treatment is a function of relatively low levels or professional experts in addiction medicine. Part of the low levels of professional addiction experts is the result of inadequate addiction medicine training of medical students and residents. ⋯ In prescribing, what constitutes legitimate follow-up of patients on antidepressants and antianxiety agents, including how to avoid additional substance abuse problems when prescribing sedative-hypnotics? 3. When and how should patients be referred to a psychiatrist? Finally, it is important to note that any of the potential changes described in this article need to influence only 10% of the approximately 17 million current heavy drinkers to seek treatment to equal the approximately 1.7 million heavy drinkers who are now in treatment, let alone any of the approximately 50 million current at-risk drinkers, virtually none of whom are in treatment. Among other social changes that will alter the future of addiction treatment, the integration of addiction into traditional medicine may go a long way in altering the current ratios of who seeks treatment and is willing to participate in treatment.
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The safest pain treatment strategy for an individual at risk or recovering from addiction is a nonopioid and benzodiazepine-free approach. If an opioid treatment is necessary, the extent of the risk can be stratified by the use of a biopsychosocial assessment and opioid screening tools. Individuals at high risk should have the greatest amount of structure and monitoring. ⋯ Both the provider and the patient need a personal investment in the treatment plan and protocol to increase the safety of opioid treatment. New medications and treatment monitoring are being developed to provide maximal relief for the patient while protecting the public health. The optimal ingredients for safe opioid treatment include a strong provider-patient relationship and clinician training in the assessment and treatment of addiction and pain.
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Psychiatr. Clin. North Am. · Jun 2012
ReviewNew systems of care for substance use disorders: treatment, finance, and technology under health care reform.
This article outlined ways in which persons with addiction are currently underserved by our current health care system. However, with the coming broad scale reforms to our health care system, the access to and availability of high-quality care for substance use disorders will increase. Addiction treatments will continue to be offered through traditional substance abuse care systems, but these will be more integrated with primary care, and less separated as treatment facilities leverage opportunities to blend services, financing mechanisms, and health information systems under federally driven incentive programs. ⋯ The problem for addiction care, as it becomes more “mainstream,” is to not comfortably feel that general slogans like “Treatment Works,” as promoted by Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment during its annual Recovery Month celebrations, will meet the expectations of stakeholders outside the specialty addiction treatment community. Rather, the problem is to show exactly how addiction treatment works, and to what extent it works-there have to be metrics showing changes in symptom level or functional outcome, changes in health care utilization, improvements in workplace attendance and productivity, or other measures. At minimum, clinicians will be required to demonstrate that their new systems of care and future clinical activity are in conformance with overall standards of “best practice” in health care.
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Opioid dependence in the setting of pregnancy provides a distinct set of challenges for providers. Treatment plans must take into consideration psychiatric and medical comorbidities while balancing risks and benefits for the maternal-fetal dyad. ⋯ Buprenorphine as maintenance treatment of opioid dependence during pregnancy has promise and may offer some benefits, but more research is needed, especially regarding induction of actively addicted women during pregnancy. For the present, methadone maintenance remains the standard of care for agonist treatment of opioid dependence in pregnancy against which other treatments must be compared.