Foundation of Addiction Medicine 2019

Interpretation of
Drug Test Results

251

Positive Test Result Interpretation

● Indicates that drug(s) or

metabolites, tested for, were

detected in the sample tested

● Drug presence is above the “cutoff”

level

● Greatest confidence achieved with

confirmation

● ALWAYS confirm positive results in

original sample 252

Negative or None Detected
Results

● Indicates that no drugs or metabolites, tested
for, were detected in the sample tested

● Negative does not mean NO drugs present .
Actually it is below the cutoff value

253

Take home message

● Urine drug screens are valuable tools in health
care, the workplace, and other settings

● Drug testing should not be used as “Punitive”
● Rather this enhances engagement, opens up for

discussion and decreases hostility
● Accurate interpretation of the validity and reliability

of these tools is critical for making decisions
● The cut-off value and Length of time is critical for

interpretation
● History of concomitant other medications important

to rule out False-Positive result

(use of Ibuprofen or Naproxen can cause potentially false positive for THC/cannabis
screen)

254

● Mr A urine was screened and came positive.
He is considering quitting. He has stopped a
week back

● We have a joint session with him and his
parent.

● Decided that we will follow the Urine testing
report as an evidence for his commitment

● Expect after two weeks urine will come
negative

● If not, mutually a common path has to be
discussed.

● A written contract was signed

255

Further reading

1. Article: Moeller KE, Lee KC, Kissack JC. Urine
drug screening: practical guide for clinicians.
InMayo Clinic Proceedings 2008 Jan 1 (Vol. 83,
No. 1, pp. 66-76). Elsevier.

2. Video. youtube.com/vknnimhans
https://www.youtube.com/watch?v=Mosqgqyf89A

256

Thank you

257

Vulnerability : Why some get
addicted and majority don’t!

Dr Arun Kandasamy
Additional Professor of Psychiatry
Centre for Addiction Medicine, NIMHANS
[email protected]

258

Conceptualization
Consequences of SUD
Psychopathology
Vulnerability

259

Vulnerability

260

NORMAL ADOLESCENT BRAIN &
BEHAVIOURAL DEVELOPMENT

261

Normal Adolescent Brain

• Adolescent brain – Not a finished product but
the work is in progress.

http://ircmentorcollaborative.org/wp-content/uploads/2014/02/teen-brain.png

262

Adolescent Brain-Changes

• Improving efficiency and decreasing the metabolic
load

– Myelination
– Synaptic Pruning

– Grey-white matter ratio

263

Myelination

Like providing a growing city with a fast and integrated
communication system

264

Synaptic pruning

• Removal of excess,
unhelpful connections
(synapses)between
neurons

In a growing city,
the road
frequently
travelled will be
strengthened and
the least travelled
will be left uncared

265

Brain timeline

Maturation progress from 266
posterior to anterior –
Brainstem to Prefrontal
Cortex

SO WHAT?

267

Behavioural Equivalents
Cognitive • Prefrontal activity

• Impulsivity and risk taking

control

Need for • Ventral striatum
• Sensation seeking and
reward
experimentation

Poor executive function is associated with
increased risk-taking behaviour.

268

Risky for a spectrum of high risk
behaviors

Violence , risk-taking and accidents
Low effort/ High excitement activities
High risk sexual activity, unexpected
pregnancy
Depression, inappropriate anger &
other emotional problems
Deliberate Self Harm and Suicide
Oppositional behavior, conduct
problems
Experimenting with substances

269

Vulnerabilities

270

Vulnerability - Temperamental
Pathways

271

Vulnerability - Temperamental
Pathways
- Internalizing Spectrum

• Distress expressed internally
• Low self esteem
• Depression and Anxiety
• Passivity/ Passive- aggressive
• Procrastination/ Avoidance
• Poor communication skills

- Krueger et al,1998

272

Vulnerability- Temperamental Pathways
- Externalizing Spectrum

• Distress expressed outwards
• Deviant behaviours
• ASPD, CD, ODD, ADHD
• Emotional instability
• High novelty seeking/ Low harm avoidance

– Krueger et al.1998, Chan et al 2008

273

Vulnerability– Temperamental
Pathways - Autistic Spectrum

• Difficulty with social understanding and relationships
with adults and children

-Aloof /Passive /Active but odd /over-formal, stilted
group

• Difficulty with social communication and language

• Difficulty with social imagination (i.e. difficulties with
flexibility of thought and behaviour)

http://www.leicspart.nhs.uk/Library/ASDPathwayversion88240815.pdf

274

Vulnerability– Temperamental
Pathways

• Internalizing Spectrum Pathway

• Externalizing Spectrum Pathway

• Autistic Spectrum Pathways

These 3 are not mutually exclusive

syndromes. 275

Vulnerability - Family History or
Heritability towards Addiction and
mental illness

276

Vulnerability

277

Vulnerability- Comorbidity

278

Vulnerability- Comorbidity

• Psychiatric comorbidity - (ADHD, CD, ODD, SLD,
ASD, Depression, Anxiety, Psychosis, Bipolar
Disorder, PTSD)
• Medical comorbidity - (STDs, chronic physical
health issues, etc.)

279

Vulnerability- Comorbidity

280

Vulnerabilities

281

Vulnerability – Developmental /
environmental stressors

282

Vulnerability – Developmental
stressors

• Adverse Childhood Experiences
• Physical/emotional/sexual abuses
• Victims /exposure to violence/
• Aggression in family/
neighborhood
• Parental neglect
• Poverty/ Malnourishment
• Exposure to toxic chemicals/ drugs
• Loss of significant other
• Peer deviancy

283

Vulnerability –Family Pathology

• Family History of Substance Abuse/ Mental Illness (Chasin
2002, King and Chasin 2007, Maalouf, 2010)

• Parent-Parent interaction (Amato, 2000, Hayathbakhsh et al, 2006, Elite, 2006)

• Single parent family

• Parent-Child interaction (Brook et al 1990 & 2009, King and Chasin 2004)
• Interaction with siblings
• Socio economic & cultural factors
• Assessment of the support system
• Child headed house and situations - (Meghdapour et al, 2012)
• Adolescent employment (Kaestner et al, 2013)

284

Susceptibility to Addiction

ASPD, CD, ADHD; Bipolar disorder,
Anxiety dis, SCZ
Novelty seeking [SS], Reward
Dependence, Harm Avoidance

Family History of Toxic Stress
Addiction Poverty, violence,
poor parenting in
Susceptibility
to Addiction childhood

285

286

Summary of Assessments

Consequences • Complications of SUD

• Complications of
other high risk
behaviour

• Addictive behaviours

Psychopathology • Other High risk
behaviours

• Comorbidity

Vulnerability • Family history +ve

• Developmental
stressors

• Temperament

287

RELEVANT TREATMENT AND
PREVENTIVE INTERVENTIONS

288

Treatment Intervention

• Mentoring Programs for High risk group
• Treatment for underlying psychopathology (Compton 2007;

Pettinati et al 2013)

• Attempt to change the risk and protective factors
• Group and family interventions
• Nurturing environment

289

Preventive Interventions

• Target will be the age group and not the specific
substances

• Interventions appropriate to developmental stages
• Targets skill building which is not specific to SUD
• Needs to be a multipronged strategy
• Involving all the stakeholders (family members, teacher,

Peer group)
• Enhancement of protective factors
• Treatment interventions
• Tough to evaluate the effectiveness

290

Take Home Message

291

Assessments Treatments

Consequences 292

Psychopathology

Vulnerability

Thank you

Dr Arun Kandasamy
Additional professor of Psychiatry
Centre for Addiction Medicine,
NIMHANS
[email protected]

293

Role of Psychosocial factors
in Substance Abuse

Ms. Karishma Khan 294
Psychiatric Social Worker
NIMHANS Digital Academy

Educational objectives

◈ Introduction
◈ Domains
◈ Interventions
◈ Evidences
◈ Summary

295

Introduction

◈ Substance abuse and dependence is
a public health crisis

◈ Long lasting and persistent
◈ Challenging to treat as it is a

relapsing illness
◈ Not just the problem for the user
◈ Tremendous pressure in the family

both emotionally and economically

296

◈ To what extent psychosocial factors
are to be considered while treating
Substance Abuse?

◈ How should we deal with them?

297

Sli.do question

#foam What according to you are the
Psychosocial factors which play a
major role in Substance abuse?

298

Brief review of few cases discussed in FoAM

◈ Master M, 17 years old male, Class 10th dropped out, started
using substances at the age of 14 years because of peer pressure,
easy availability, and had experienced parental neglect - A case of
Opioid Dependence

◈ Mr. A 23 years old unmarried male, B.Com dropped out, started
using substance at the age of 14 years just for fashion and status
maintenance, easy availability, peer pressure, break up with
girlfriend - A case of Opioid Dependence

299

Cont...

◈ Mr. R, 32 years old married male, his father had alcohol
dependence due to which family had financial constraints
resulting in him dropping out from Class 8th, started using
substance at the age of 10 years as he started working as labor to
support the family, peer pressure, workload, financial stress - A
case of Alcohol Dependence

◈ Mr. K, 26 years old unmarried male, dropped out B-Tech, doing a
private job, started using anonymous tablets during the time of
examinations to increase concentration and to avoid sleep at
night, experimenting with alcohol and smoking, due to peer
pressure, could not resist using alcohol, irritable, abuses and
assaults family members, breaks articles and things at home - A
case of Substance induced Psychosis

300