PPS IV Test

FASD Prevention Messages

No safe time and no safe amount If you are pregnant, don't drink If you are drinking, don't get pregnant If you can't quit, get help The effects of alcohol on the fetus are permanent

Relief Craving: Role of Norepinephrine

Norepinephrine (NA): Produced in Locus Ceruleus (LC) Stimulates wakefulness

Types of Therapy Groups

Self-help Interpersonal Cognitive therapy Modified dynamic Relapse Prevention Specific populations (adolescents, females, elderly, etc)

Distressed Physician

Also called the Disruptive Physician Is a physician who through behavior jeopardizes patient safety Examples: Angry, Passive-aggressive, Belittling , Blaming, Sarcastic, etc.

'Other' Associated Structural Abnormalities

Limb abnormalities Crease differences ('hockey stick' crease) 5th clinodactyly Cardiac malformations Ocular abnormalities Skeletal deformaties Auditory deficiencies

Sexual Differentiation of GI

- Chromosomes - Genes - sex chromosomes - genitalia - hormones - other factors(??) - Brain (+ the phenotype) → induce environmental features and the Brain adapts to environmental features, simultaneously and continuously

The Human Condition

- Drug abuse does not occur in a vacuum; we are all subject to influences beyond our control: a. Genetic Propensities (up to 1/3 of all people) b. Basic Neurochemical Makeup c. Psychological Dispositions d. Social Conditions e. Existential Vacuum (sense of meaninglessness in life)

CDC Criteria (2004)

- Dysmorphology Head circumference < 10th %centile and other growth criteria - Associated Structural & Functional Abnormalities Brain abnormalities observed via Imaging Seizures Impaired motor skills

Male Hypoactive Sexual Desire:Biological Factors

- Medical problems a. Hormonal deficiencies (testosterone, thyroid) b. Diabetes mellitus c. CNS diseases d. Other Chronic illnesses - Medications a. Antihypertensives b. Antidepressants c. Some hormones for advanced prostate cancer and breast cancer)

Advances in Research => choline

- Prenatal choline supplementation mitigates behavioral alterations associated with prenatal alcohol exposure in rats. - Choline supplementation during prenatal alcohol exposure may reduce the severity of functional alcohol affects on the developing nervous system

Addictions at End of Life

- Substance abuse in patients at end of life who do not have a previous history is rare - Clinical problems: a. Poor compliance with treatment b. Poor prognosis c. Shorter life expectancy d. Poor social support networks e. Pain inadequately treated

Chronic Opioid Therapy

- Explicitly discuss with the patient: a. Possibility for life-long opioids b. Continuous management of side effects: 1. Driving risks 2. Overdose risks 3. Abstinence syndrome (physiologic withdrawal) 4. Sleep apnea 5. Hypogonadism - Informed consent agreement - Continuous urine drug testing - Limit dose below 100-120 mg MED. - Get help early when not going according to plan.

Contingency Management

- Systematic application of positive reinforcement to achieve therapy goals a. Abstinence from drug use b. Retention in treatment c. Attendance at therapy sessions d. Compliance with medication management - Based on operant conditioning - Great for inducing abstinence - Voucher-based or fishbowl procedure

Sexual Differentiation Brain & behaviors

- T → Brain -the male brain differentiates via timing of exposure dosage of exposure duration of exposure - Inadequate or inappropriate exposures → "ambiguous" gender-related behaviors, attitudes,... But GI??

Sexual Differentiation => genitalia

- T → DHT → genitalia and other organs differentiate via the timing of T exposure dosage of T exposure duration of T exposure And these 3 points are likely crucial to → typical diff.

Crack Baby - the lost generation

"Severe, irreversible damage, including reduced intelligence and social skills"- a gross over exaggeration. Cognitive performance, information processing, and attention to tasks—may be affected. —abilities that are important for the realization of a child's full potential.

High Risk for Drug/Alcohol Interactions

- Take more prescription and OTC meds than younger people - Aging body more susceptible to adverse reactions - Slowed metabolic and clearance mechanisms delay resolution of adverse reactions

Dependence

A state in which an organism functions normally only in the presence of a drug Manifested as a physical disturbance when the drug is removed (withdrawal)

What Increases Denial

- guilt and shame - confrontation - fear

Putting It All Together (final)

- Chronic pain + addiction: a. Use non-opioids for pain, if possible. b. Use functional goals to guide treatment planning. c. Consider the need for agonist therapy for opioid dependence. d. Avoid benzodiazepines & other sedating agents. - Use a biopsychosocial approach for both disorders. - Do drug testing. - Follow prescription monitoring program data. - Get help early.

Appropriate Treatment Strategies for family interventions

- Family Interventions a. One or two significant people in an older adult's life confront the older adult about their drinking problem under the guidance of a skilled counselor. b. Confrontation by younger relatives should be avoided because it increases shame in the older adult. c. Labels such as "alcoholic" should be avoided

2010-Present

- HPTN 052 shows 96% reduction in HIV transmission within sero-discordant couples (nearly all heterosexual) with early initiation of ART1 - 2013: DHHS guidelines recommend ART for ALL patients with HIV infection. a. This in large part to decrease transmission and therefore to prevent new infections. - 2 patients in Boston with HIV who underwent BMT for Hodgkin's Lymphoma have recurrent HIV viremia after ART is discontinued.

Female is primary: embryo birth

- unfettered, the human phenotype is female (prepuberty) - Gonads → ovaries in face of 46 chromosomes w/ XX → 1st chromosome (Chr 1) has Wnt4 + RSPO1 → drives gonadoblastema into ovaries ~ week 6-7 - Organogenesis, growth, birth, puberty (an explosion)

Sexual Behavior: Global Perspective

- Age and sexuality a. No universal trend towards earlier sex - Shift towards later marriage in most countries → ↑ premarital sex a. More premarital sex in developed countries b. Higher in men than women - Married people report more sex in previous month a. Married:nonmarried sex up to 9:1 in some countries

The "Invisible Epidemic" & elderly

- Alcohol abuse takes a greater toll on elderly - May accelerate aging associated with decrease in physiological functioning - May increase risk for injury, illness, socioeconomic decline

OHPP

- Helping Health Care Providers Having Problems in their Professional & Personal Lives - OHPP has been a Model Program in the Nation. => What makes us unique is our relationship with our Medical Boards. - We work with MDs, DOs, PAs, Vets, Dentists, Psychologists, Residents & Medical Students. In past also worked with Allied Health.

Stimulant Withdrawal

- "Crash" with discontinuation after prolonged use a. Depression +/- SI b. Fatigue c. Extreme cravings d. Anhedonia e. Anxiety f. Insomnia/hypersomnia g. Increased appetite h. Psychomotor retardation - Withdrawal symptoms not uniformly reported

Who Should be Screened?

- All patients 60+ - If younger than 60, screen if: a. undergoing major life changes (Menopause, "Empty Nest Syndrome", Retirement, Death of spouse/partner, Assuming a "caretaker" role) b. exhibiting physical symptoms of possible alcohol use disorder (Incontinence, Neglected hygiene, Restlessness, Change in eating, Slurred speech, Tremor/motor problems, Falls/bruising, Difficulty sleeping, Cognitive problems, Seizures, Malnutrition, Liver problems, Irritability, depression, Unexplained somatic complaints)

Female Orgasmic Disorder (Biologic factors & treatments for psychological factors)

- Biological factors may contribute a. Antidepressants (SSRI's) b. H2 blockers (cimetidine) c. M.S., neurologic damage d. Vaginal dryness, pelvic problems (not necessarily menopause) - Treatments for psychological factors a. Enhance communication of what partner needs b. Masturbation first, transferring to couple c. For psychological problems, psychotherapy indicated 1. Process issues of past sexual or emotional abuse, poor body image d. Other marital problems: conflict or affair 1. Restore trust in relationship

Sexual Desire Disorders: Other Treatments (Men & Women)

- Biological issues a. Treat testosterone deficiencies (women: Estratest, patches, creams) b. Lubricants c. Treat significant depression and anxiety d. Identify offending medications, medical problems - Other psychological issues Address relationship problems Psychological conflicts: psychotherapy, especially for history of sexual abuse or repressive upbringing

Treating An Opioid Use Disorder

- Biopsychosocial model of treatment - Biological: a. Pharmacologic Management - detoxification vs maintenance Treat any comorbidities - Psychological: Group therapy, +/- individual therapy, dealing with underlying psychiatric issues - Social: a. Self-help group attendance b. Attend to environmental contextual issues (e.g. housing, finances, case management, etc.) - Monitor urine drug testing - make sure lab tests for the patient's opioid of choice If positive, re-evaluate the treatment plan. a. Positive test results do not indicate a need for termination of treatment, but rather, they indicate a need for a higher level of care.

Childhood

- Both sexes - Growth and development - GI? - GR? - SO? Personality and temperament Adaptation to and activation of environment

Sexual Differentiation - Brian & Errors of T

- Brain differentiates (including) in terms of GI GR SO (related to timing, dosage, or duration of T?) and - → Errors of T exposure prenatally: GI → Gender Dysphoria; atypical GR behaviors; SO →?

Attitudes Toward Sexuality

- Historically: what is normal sexuality is difficult to define and depends on time & place. - Europe and Western civilization: oscillation between liberalism & puritanical repression (Renaissance & Reformation) - Recent U.S. history 1960s-80s: liberal sexual attitudes 1990s-present: more conservative trend (? 40% fear AIDS) 2000s-10s: more acceptance of diversity

Sex & Cardiovascular/ Respiratory Problems

- Cardiovascular a. Post-M.I. (most research) 1. Isometric exercise ↑↑ B.P., so missionary position not best at first 2. Masturbation => May be best way to resume sex after abstinence & Not as stressful on heart b. Congestive heart failure 1. Arrhythmias should be controlled before sex resumed - Chronic Obstructive Pulmonary Disease (COPD) a. Coughing, wheezing worsened under stress b. Side by side penetration may ↓ energy required c. Bronchodilators, intercourse in AM when rested

Prevalence Among Health Professionals

- 10-12% Lifetime prevalence- we used to think it was much higher than general population. - 0.5 - 1% Annual incidence (new cases) - Suicide Rate> general population

Brief Therapy Interventions

- 10-30% of problem drinkers reduce their drinking to moderate levels following BRIEF INTERVENTION - A brief intervention - one or more counseling sessions, which may include motivation for change strategies, patient education, assessment and direct feedback, contracting and goal setting, behavioral modification techniques, and the use of written materials - Cognitive Behavioral Therapy - The Frames Model: Feedback, Responsibility, Advice, Menu, Empathic, Self-Efficacy

A landmark finding

- 1995-96: a. HIV viral load testing available b. David Ho is Time "Man of the Year" 1996 c. First protease inhibitors approved by FDA

Lesbian, Gay and Bisexual Issues

- 1999 NYC Study of 65 and over a. 65% lived alone vs 35% of heterosexuals b. 20% lived with a partner vs 50% of heterosexuals c. Studies suggest they are not lonely. - May not talk as openly about their relationships - especially if Pre - Stonewall 1969 - Need to identify who is appointed health care proxy

Estimates of Alcohol Use Among Older Adults

- 2% to 15% of community-based elders exhibit symptoms consistent with alcoholism - 10-15% of older primary care patients met criteria for problem drinking - 8.6% patients (N = 140) in a geriatric mental health outpatient clinic met criteria for alcohol dependence - 21% of older adults hospitalized for medical conditions abuse alcohol - 1 in every 10 patients in a medical setting and 1/5 hospitalized older patients is most likely to suffer with an alcohol problem.

Different Sexual Preferences

- 2-10% adults have different sexual preference a. Internal craving, what is interesting b. Behavior may not be consistent with preference 1. Social stigma affects behavior c. Preference appears not to be chosen--only choice is whether to act on preference - Studies show gays in general have higher educational level; fewer devoutly religious

Zygote to embryo - Male or Female?

- 23 pairs of chromosomes, but one is asymmetrical: 46, XX Classic female 46, XY Classic male but sans chrom sym - X is robust (how do F avoid trisomy effects?) Y is miniscule (25 or 30 transcribed genes) - But... Y Chr has Sry = sex determining region of Y — but actually a gene

DRUGS OF ABUSE

- AMA ESTIMATES that 10% of all physicians are impaired at any given time - 20 years ago it was observed that statistically, the equivalent of 7 entire medical school classes are lost annually to alcoholism, drug addiction and suicide

ADDICTION

- ASAM - Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. - Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. - This is reflected in an individual pathologically pursuing reward and/or relief through substance use and other behaviors.

Culturally Appropriate Assessment Measures

- AUDIT-Cross-cultural studies (Babor, 1992) - Addiction Severity Index (ASI) (McLellan, 1980) a. Native Americans b. 1 hour face to face interview c. highlights seven potential problem areas: medical status, employment and support, drug use, alcohol use, legal status, family/social status, and psychiatric status. This broad overview helps to determine the client's level of stability. It has also proven useful for understanding life events that contribute to alcohol and drug dependency.

Basic Pharmacology

- Absorption Stomach/GI tract Gender differences - Distribution - Metabolism and elimination a. Genetic differences b. Liver 1. Maternal 2. Fetal

How to understand addiction

- Addiction can best be understood as something that involves every dimension of a human being: a. Biological (your body and brain) b. Psychological (your mind) c. Interpersonal (your social world) d. Spiritual (your existence)

Neurobiology

- Addiction is a brain disease - It appears that behavior is often a negotiated process with input from various areas of the brain. - The mesolimbic system of the midbrain or "pleasure center" is a powerful stimulant of addictive behavior. - In mice that like alcohol it has been found that they have different serotonin receptor than other mice. - The PET scan has been a useful tool in looking at obsessive compulsive disorders. - These driven behaviors appear to emerge from hyperactivity in various locations in the midbrain structures.

Questions to consider

- Are you experiencing any problems in your sexual life? - Some people on these medications notice sexual problems. - Is that something that has affected you at all? - Sometimes when people feel very low and depressed => they lose all interest in sex. Do you think that is an issue for you? - Often women around the time of the menopause can suffer not only with the hot flushes you have described but also with sexual problems such as vaginal dryness. - Is that something you have experienced?

Periodic Review

- Assess the safety and efficacy of treatment (e.g., subjective pain ratings, functional changes, improvement in quality of life, side effects of opioids) - Assess for compliance and evidence of misuse - Reassess the nature of the pain complaint to confirm that opioid treatment is still warranted

Repeat Screening

- At least annually for all persons at high risk of HIV infection: a. Injection-drug users (IDUs) b. Sex partners of IDUs c. Persons who exchange sex for money or drugs d. Sex partners of HIV infected e. Men who have sex with men (MSM) f. Heterosexuals who themselves or their sex partners have had >1 sex partner since last HIV test - Before new sexual relationship

Classifying Drinking Practices and Problems Among Older Adults

- At-Risk, Heavy, & Problem Drinking a. At-Risk 1. One whose patterns of alcohol use, although not yet causing problems, may bring about adverse consequences. b. Heavy/Problem Drinking 1. Signify more hazardous levels of consumption. - Special Considerations a. Threshold for "at risk" drinking decreases with advancing age b. Distinction between "heavy" and "problem drinking" narrows with age

2000-2010

- Awareness that HIV is a chronic disease - Recognition of long-term toxicities to ART: - Simpler, once daily regimens with fewer pills - Setbacks for vaccine research1 - Observational data suggest that earlier initiation of ART is associated with reduced morbidity and mortality2 - The "Berlin patient" a. 40 year-old HIV-infected man with AML received an allogeneic SCT from a donor homozygous for the CCR5 D32 allele associated with natural resistance to HIV infection3

History of HIV

- Circa 1900: From Monkeys to Humans a. Between 1884 and 1924, (target date 1908) somewhere near modern-day Kinshasa in West Central Africa, a simian retrovirus (SIV) is transmitted from a chimpanzee to a hunter- mutates and become HIV-1 group M. b. Three distinct SIVCPZ viral lineages c. SIV transmitted from Sooty mangabeys to humans becomes HIV-2 - Identification of HIV-1 infection in archived blood sample obtained in 1959 from man in Kinshasa. - 15 y/o boy who died in 1968 of Kaposi's sarcoma stored serum tests HIV-antibody positive in 1980s

Motivational Enhancement

- Classical Understanding of Addictions: a. Individual had sole responsibility for becoming motivated to stop substance use. b. Individual had to hit "rock bottom" to have enough consequences to stimulate abstinence - Modern Understanding: a. Screen & refer to treatment b. Many presenting to treatment will be ambivalent. c. Provider can improve the individual's motivation.

Twelve-Step Facilitation (cognitive, emotions, social & spirtiual)

- Cognitive - Increase awareness of the cognitions associated with their substance use, many of which are frequently addressed in AA/NA - Emotions - Improve awareness of the emotions frequently associated with use. (e.g. Hungry, Angry, Lonely, Tired) - Social - Engage in actual attendance at meetings & work with a sponsor - Spiritual - Develop trust in a higher power => Spirituality - "That which gives meaning & purpose in life

Homosexual Culture: Socialization

- Coming out" (of the "closet") - Person begins to act on internal sex preference - Not a public declaration - Problems facing gay teens - 30% teen suicides: sexual identity issues => 6x greater risk for suicide a. Often face ostracism, criticism, violence (consider support groups for gays and family--PFLAG) b. In conservative communities, parents may kick out gay teen, (may become "hustlers")

The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?

- Committee on the Mental Health Workforce for Geriatric Populations concerning professionals entering into geriatric mental health/substance use - Essential ingredients for effective services a. Systematic outreach and diagnosis b. Pt and family education and self-management support c. Provider accountability for outcomes d. Close follow-up and monitoring to prevent relapse e. Patient centered f. Accessible (PCP, senior centers, or home-based) g. Coordination of care by trained personnel with access to specialty consultation

Prenatal Development: "Embryology 101"

- Conception and cell division - Segmentation and organogenesis—the gonads - Genes, Gender, Genitalia + epigenetic/environ

Prenatal development

- Conception, cell division, segmentation, organogenesis - Genetics, induced environment(s), epigenetics

Asking Screening Questions

- Confidential setting - Non-threatening, non-judgmental manner a. Medical vs Psychiatric diagnosis b. Avoid stigmatizing terms (e.g., alcoholic) c. Prepare patient rather than blindside - Collateral report may be necessary a. Get permission b. Be ready for emergence of anger toward patient

Uniquely Vulnerable

- Drinking can be hazardous for elderly even when formal AUD diagnosis is not warranted a. Decreased body water, Increased sensitivity/decreased tolerance, & Decreased metabolism in GI tract - Combination of age-related changes and drinking can increase risk for: a. Hypertension, arrhythmia, infarction, Hemorrhagic stroke, Decreased immune system function, GI bleeding, Malnutrition, Depression, Decreased bone density (?) - Quantity of alcohol consumed and frequency of drinking can only serve as rough parameters in this population a. Age appropriate assessment techniques are not well known. For example, typical assessment involved QF, but this can only serve as a rough parameter in this population given individual differences, such as prescription medication regime.

SEXUAL BOUNDARIES

- Considered by Medical Boards to be the worst behavior a physician can engage in. - The physician has all the Power in the relationship, therefore physician abusing the patient. - Even a so called "Consensual Relationship" is an Abuse of the trust of the Physician-Patient Relationship. - There really is no statute of limitations. - Even a one time encounter is misconduct - Often the Physician has a Relationship or Love Addiction - Males >> Females - If you had relationship first, then see them as a patient, can be considered boundary violation. - JUST SAY NO!!!

Premature Ejaculation

- Consistent condition in which male ejaculates too quickly (within 1 min. after penetration, or before desired) a. Present for 6 months and causes distress b. Not due to other mental disorder, severe relationship distress or stressors, substance or medical condition - Specifiers: Lifelong vs. acquired Generalized vs. situational Mild, moderate or severe - Characteristics a. May depend on age, novelty of partner, or recent frequency of sexual activity b. Male has not learned to gain conscious control of reflex in lumbosacral area c. Not under voluntary control d. Not correlated with internal conflict about sex, marital status, economic status, ethnic group

Never-ending cycle

- Cycle of Neuroadaption and craving is a spiral that, if not interdicted, will lead to self-destruction and eventually death.

Female Sexual Interest/Arousal Disorder

- Decreased sexual interest/arousal with 3: a. Decreased interest in sex b. Decreased sexual fantasies c. Doesn't initiate sex and is unresponsive to partner d. Decreased arousal in response to erotic cues e. Decreased genital or nongenital sensations during sexual encounters (doesn't lubricate, etc.) - Causes distress and lasts for 6 months a. Old term: frigidity - Specifier: Lifelong (primary) vs. acquired (secondary) Generalized vs. situational Mild, moderate or severe

Gender Identity

- Definition: internal sense of being M or F a. May not be consistent with biological sex b. Established early, probably by age 2 - Drs. Reiner, Wisniewski will clarify Gender Development (Gender Identity & Gen.Dysphoria) - Gender identity influenced by many things a. Biological factors b. Partly learned

Gender Identification (Gender Role, Gender Expression

- Definition: public expression of who you are a. Masculine or feminine behaviors, appearance b. Partly learned from significant others c. External behaviors - Socially imposed rules, values - Early life experiences (rape, caught "playing doctor") - Presence of clear role model a. Helpful in single parent families: same sex role model

Chronic Pain & Addiction

- Determine if opioid maintenance therapy is warranted for opioid dependence. a. Need urine HCG, CMP, CBC, EKG as baseline for buprenorphine or methadone. - Closely monitor UDS and Oklahoma Prescription Monitoring Program. - Treatment agreement signed. - If on methadone maintenance, monitor EKG & watch for drug-drug interactions. - Manage chronic pain & addiction concurrently a. For pain, use non-opioids if possible - closely watch drug-drug interactions b. CBT/Mindfulness for pain c. Physical therapy, encourage physical fitness d. Group & individual therapy, case management, self-help programming - Seek assistance of addiction and pain management specialists if in doubt.

Pharmacologic Treatment of Opioid Dependence

- Detoxification - high dropout and relapse rates, despite the length of the detox, whether detoxing with opiates or non-opiates a. 82% relapse within 12 months of getting off b. 45% relapse within 3 months of getting off - Opioid Maintenance Treatment - traditionally considered stable dosing beyond 30 days a. Methadone, Buprenorphine-Naloxone - Opioid antagonists - naltrexone, naloxone

Other Medical Problems & Sex

- Diabetes Mellitus (poorly controlled) a. Peripheral neuropathy: loss of feeling in genital area may require ↑stimulation b. Glucose fluctuations ↑ fatigue, ↓ sex drive interest c. Female diabetics: changes in vaginal pH →secondary yeast and bacterial infections - Hypertension a. Antihypertensives may alter blood flow and impair erections

Treatment of Genito-Pelvic Pain/Penetration Disorder

- Different positions: requires cooperation a. female needs to identify least painful position b. flexibility important - Treatment of vaginal tightening a. Deep muscle relaxation techniques first b. Vaginal dilators of increasing size inserted by woman to help relax vaginal musculature c. Female controls insertion of dilators, later penis - Medical evaluation important to diagnose infections and physical problems a. Lubricants

Withdrawal/Negative Affect

- Disrupted reward systems - decreases in reward neurotransmitters Acute withdrawal Negative motivational state - Anti-reward systems - CRF & Norepinephrine Emotional dysregulation - abnormal stress response Craving

Sexual Desire Disorders: Behavioral Treatments (Men & Women)

- Education, communication a. Change self-defeating attitudes, performance anxiety b. Educate about sexual skills and knowledge c. Improve sexual communication - Sensate focus exercises a. In private, couples first stimulate non-genital areas (not breasts) b. Provide pleasure under relaxing, non-demanding conditions 1. Trial and error learning about giving and receiving pleasure (fondling, massaging) 2. Giving partner's only responsibility is learning about receiving partner's sensate preferences 3. Receiving partner's only responsibility is directing giving partner as needed Gradual increase in foreplay, sex without pressure

Endogenous Cannabinoid System

- Endocannabinoids - Cannabinoid receptors

Natural stimulants

- Ephedra Plant - Khat plant, Catha edulis - harvesting coca - Erythroxylon coca plant

Biological Treatments of Female Sexual Interest/Arousal Disorders

- Eros (Clitoral vacuum device) - Oral medications a. None yet specifically developed for women b. Possible benefit for a few from sildenavil (Viagra) (?younger)—off label c. Low dose testosterone sometimes used (creams, patches) d. Under investigation: 1. Medications for females 2. Oral phentolamine (Vasomax) 3. Apomorphine (Spontane) => brain stimulation, vasocongestion

Treatment Plan and Objectives

- Establish a working diagnosis and medical indication for treatment with opioids - Outline measurable outcome objectives (e.g., pain control, improvement in activities of daily living, functional improvement, etc.) - Provide informed consent on the risks and benefits associated with opioids - Discuss the conditions under which opioids will be prescribed and discontinued

Pleasure Chemistry

- Every drug of abuse relates in some way back to the brain's pleasure chemistry; a. All neurological activity of drugs of abuse will have an effect upon the norepinephrine, dopamine, or serotonin pathways within the limbic areas of the brain--

End of Puberty

- Males become what the embryo, the fetus, and the child have been aiming for all along, the endpoint, the becoming of an individual adult self (male) - Females become the individual adult self (female) - but with the power of creation - Not only are M and F diff, puberty magnifies the diff

Barriers to Treatment

- Few elders are screened for alcohol problems a. Less obvious signs of problem drinking - Transportation problems a. Driving after dark b. Evening aftercare/AA c. Rural communities lack public transportation d. Poor urban communities; dangerous - Lack of social support a. Shrinking circle of friends - Financial issues a. May not have adequate insurance coverage b. Fixed income - Homebound ("Shut-Ins") a. Extremely high risk for alcoholism b. Frequently have limited mobility (weak/frail) c. Always requires assistance of others 1. Socially isolated d. Leaving home requires considerable effort

Frotteuristic Disorder

- Frotteur repeatedly touches or rubs body against nonconsenting person for sexual stimulation a. >6 mo, causes distress or impairment b. Often in crowded public area (bus, crowded subway), esp. in big cities 1. Don't confuse with person accidentally bumping against you on crowded elevator c. Usually a passive and isolated person 1. Frottage is only source of sexual stimulation - Prevalence: population prevalence unknown a. ≈10-14% of adult males seen in outpatient settings

WHAT IS PSYCHOSEXUAL DEVELOPMENT?

- GR, GI, and SO - Complexity, Complexity, ... - In many ways, these appear to be developmentally (largely) independent of each other, while being interrelated and intertwined throughout human development - And development is lifelong, not simply childhood or adolescence - Terms are both Reductionistic and all-encompassing

Course of Development: Gender

- Gender (sex): physiological plumbing (anatomy, physiology, chromosomes) - Embryonal gonad influenced by genetic material in sex chromosomestestes or ovaries a. Testes secrete testosteronemale genitalia 1. critical period of development b. If no testosterone, female reproductive system

Substance/Medication-Induced Sexual Dysfunction

- General: drugs of abuse in small doses may be disinhibitory; as dose , so does inhibition of sex a. alcohol: especially inhibitory in larger doses b. sedative/hypnotics: same as alcohol c. hallucinogens vary among individuals 1. some so stimulating they sensory stimulation to point sex is painful (LSD) 2. some (marijuana) initially enhance due to disinhibition d. amphetamines & cocaine 1. release dopamine presynaptically 2. continued use depletes CNS dopamine storage => inability to experience pleasure e. opioids: decrease testosterone in M & F => decreased sex drive

Physiology of Human Sexual Response: Arousal (Excitement)

- Genital epithelial stimulation => lumbar sacral reflex a. Engorgement of genitalia without inhibition 1. Lumbar vasoconstriction (sympathetic) is inhibited 2. Sacral vasodilation (parasympathetic stimulation) - Dilation of arterioles and arteries, tonic spasm urogenital triangle muscles - Tonic spasm inhibits venous return, aiding engorgement - People learn to control sexual excitement using psychogenic center (premature ejaculators have difficulty controlling this center

Substance/Medication-Induced Sexual Dysfunction (treatments)

- H2 blockers--cimetidine (tagamet) a. H2 blocker also with blocking, can block orgasm, ejaculation - Antipsychotics (50% have sexual AEs) - Antidepressants (25-80% have sexual AEs) a. SSRI's (serotonergic) inhibit desire, orgasm b. older drugs cause alpha blockade - Other drugs: cardiovascular, cytotoxic, GI, hormonal agents

Acute retroviral syndrome diagnostic timeline

- HIV RNA by PCR Positive by 4-11 days Sensitivity 100% Specificity ~98% Suppressed by HAART - ELISA Detects circulating antibodies against HIV. Positive by 3-4 weeks. Negative during ARS Present lifelong - Western Blot Detects circulating antibodies against HIV More specific than ELISA. No more sensitive during primary infection. Present lifelong

Conclusions

- HIV is a global epidemic affecting geo-political and geo-economic events - HIV is treatable and manageable - Early detection is critical to prevent more spread - New therapy is way better what was available last century - Routine HIV screening is for: a. all patients aged 13-64 years b. all health-care settings - Current recommendations are to treatment should be offered to all individuals with HIV infection.

Attitudes Toward Homosexuality

- Homophobia a. Negative attitudes or fear of homosexuality b. Often stronger in societies with females repressed - Cultural differences: complex and vary with culture, geographic location and time - Attitudes of medical profession a. Classified as a mental illness in U.S. until 1974 b. No longer classified as a mental illness c. No maladaptive behaviors limiting functioning d. "Ego-dystonic" homosexuality describes homosexuals unhappy with sexual preference

Delayed Ejaculation

- Marked delay, infrequent or absent ejaculation most (>75%) of time (could be >30 min. - Lasts at least 6 mo, causing significant distress - Not due to nonsexual mental disorder, severe relationship distress, substance/ medication or medical condition - Specify if: Lifelong vs. acquired Generalized vs. situational

QUIZ QUESTIONS & ANSWERS - TRUE/FALSE

- In a recent study examining the effect of a media campaign on knowledge, skills, and attitudes among an African American population in St. Louis, many myths about alcohol use and FAS were uncovered through a random digit dial survey and focus groups. These myths have also been proven to be prevalent in the majority community, as well. - Many women believe that small levels of alcohol consumption are ok. Additionally, many women believe that drinking late in pregnancy is ok, and in fact will make labor easier. - Some women believe that beer and wine are not alcohol, only mixed drinks or highballs are alcohol, and thus drinking any amount of beer and wine is ok and will not cause a problem. - Some women believe that if they drank and did not have a child with Fetal Alcohol Syndrome, then they are protected from having future Fetal Alcohol Syndrome effected kids. Additionally, some women believe that FAS is genetic, and that if there are no relatives in their family tree with FAS, then their child won't get FAS either, even if they drink during pregnancy. - Lastly, some women believe that FAS is curable if diagnosed early. - Actively confronting these myths is important when educating women about the harmful effects of alcohol during pregnancy.

Toxicity/Adverse

- Increased anxiety, possible panic attacks, paranoia - Increased CSF levels endocannabinoids in schizophrenia patients a. 2-3x increased risk of developing schizophrenia b. Worsens psychotic symptoms c. Worsens prognosis of recovery from schizophrenia symptoms - Damage to respiratory system (similar to tobacco smoke) - Immune suppression - Increased heart rate, orthostatic hypotension - Increases risk of alcohol-induced liver disease - Alters almost all hormonal systems - LH, GH, prolactin, reproductive hormones, TSH, et al

Treatment of paraphilias

- Individual and group psychotherapy a. To improve emotional ties, self esteem, process early sexual abuse or neglect issues b. Social skills, sex education & training c. Requires motivation and psychological awareness - 12-Step programs - Orgasmic reconditioning a. Person self-stimulates to paraphilic fantasy or stimulus b. Before orgasm concentrates on more acceptable fantasy - Pharmacotherapy a. Antidepressants, mood stabilizers b. Anti-androgens (lowers sex drive but side effects) c. Controversial: long-acting gonadotropin-releasing hormones (medical castration)

200 Years: A Changing Society

- Industrial revolution a. Physical labor jobs => office jobs - 1970s - Supplemental Security Disability Insurance - Advances in modern medicine a. Scientific method b. Development of penicillin c. Germ theory of disease d. Pasteurization e. Lister's antiseptic technique for surgeries

FASD - The Unseen Issue

- It is estimated that for every child born with FAS, three additional children are born who may not have the physical characteristics of FAS but still experience neurobehavioral deficits resulting from prenatal alcohol exposure that affect learning and behavior." - FAS - Is only the tip of the FASD iceberg

Initial Reports

- June 5, 1981: 5 cases of PCP in gay men from UCLA (MMWR) - Dec 10, 1981: 3 NEJM papers describe cases - 1982: a. Term "AIDS" coined b. First cases in women reported c. First transfusion and vertically transmitted cases reported

Focus of Lectures

- Knowledge based: physiology, behavior, attitudes (not simply values) - Sexual behavior, not intimacy and love a. Sex ≠ intimacy b. Some have difficulty putting together sex + emotional intimacy: 1. Good sex, but when others become close emotionally, they feel smothered and destroy relationship 2. Some have good emotional intimacy, but fear sex

Human Sexual Response Cycle(Masters and Johnson)

- Lengths of phases vary a. Longest: excitement and resolution 1. Excitement: several minutes to hours M & F 2. Resolution: if orgasm10-30 min.; no orgasm ½ -1 day - Plateau short; orgasm shortest - Orgasm < 1 minute - Refractory period: no further orgasm possible a. Females: often no refractory period with multiple successive orgasms b. Males: several minutes to hours 1. Age affects 2. Some men report multiple orgasms - One complete cycle lasts from few minutes to many hours

Guidelines for Treating Chronic Pain

- Listen to your patient to learn their functional goals, rather than pain goals. - Clearly define a treatment plan to include improved function. - Screen for mental illness & addiction in all chronic pain patients. - Start with non-opioid therapies first. - Use opioids as last resort. - When using opioids, start w/ short-term trial, after which goals are re-evaluated. - When using opioids, clearly define consequences of misuse. a. Limits of your prescription writing b. Urine drug testing c. Prescription monitoring program data

Treatment

- Major Goals a. Reduce HIV-related morbidity; prolong duration and quality of survival b. Restore and/or preserve immunologic function c. Maximally and durably suppress HIV viral load d. Prevent HIV transmission e. Currently recommended for all patients with HIV infection.

Substance-Use Disorder: DSM-5

- Maladaptive pattern of use leading to clinically significant impairment or distress, in a 12-month period, at least 2: a. Recurrent use causing failure to fulfill role obligations b. Recurrent use in physically hazardous situations c. Continued use despite social/interpersonal problems caused or exacerbated by the effects of substance d. Tolerance e. Withdrawal f. Substance taken in larger amounts or longer periods than was intended g. Unsuccessful efforts to cut down h. Great deal of time spent obtaining/using the substance i. Continued use despite medical or psychiatric sequelae j. Craving or persistent desire to use

Masturbation: Statistics

- Males a. 92-97% lifetime prevalence b. Kinsey's original work: small number never masturbate 1. May not know how or may not want to 2. When person has sexual dysfunction, treatment may involve teaching them to masturbate Physician may need to give permission to begin to function sexually, then transfer pleasure to another in mutual interaction - Females a. Lifetime prevalence: 50-90% b. Voluntary mail-in survey (cross sectional): 82% - Masturbation almost universal despite myths of blindness, impotence, illness, sterility

Puberty

- Males Massive transformation and development Affecting and effecting ... - Females- affecting & effecting & Realities of creation - of life

DE: Medications & Medical Causes

- Medications include: a. SSRIs and other antidepressants b. Some antipsychotics c. Some antihypertensives d. Opioids, alcohol and drugs - Medical conditions a. Neurodegenerative diseases: multiple sclerosis, diabetic and alcoholic neuropathy b. Traumatic surgical injuries damaging pelvic nerves c. Endocrine conditions: Cushing's (↑cortisol), thyroid disease, hypogonadism

Alcohol Effects on Neurons Migration

- Migration occurs from within deep regions of the developing NS to 'outside' regions, following along 'glial' cells for guidance. - This scaffolding uses a protein guidance system allowing the cells to move into their final and appropriate positions. - They will form layers, or in some cases collections, called nuclei that may have specific function. - Each collection will send out sprouts, called neurites which will follow along chemical substrates to innervate other nerves, muscles or glands.

Medical Issues & Sexuality

- Mood (Affective), anxiety disorders a. Anxiety's sympathetic stimulation b. Depression decreases pleasure c. Fatigue: Both biological states affecting sleep - Illness a. Fatigue, pain b. Effects on circulation, endocrine c. Differential effects on sexual disorders d. Androgens important in general functioning in males & females

Birth and its Changes

- Mother responds - Others (family) respond - (newly experiencing) Baby responds - "Ambiguous" Phenotypic Baby's M has many unexpected responses → ....

Neurodevelopmental Effects of Alcohol

- Multifactorial: a. Cellular effects 1. Mechanisms such as neurogenesis, etc. 2. Membrane effects & myelination b. Metabolic Factors 1. Growth factors & adhesion molecules 2. Free radical generation c. Gene expression 1. DNA/RNA Regulation 2. Methyl transfer (choline & folate) 3. Protein synthesis (messengers/transmitters)

Best medical advise

- NO ALCOHOL DURING PREGNANCY

Non-Opioids for Chronic Pain

- NSAIDs - caution in patients with hepatic/GI, renal, or hematologic disease - Tricyclic Antidepressants* - esp. amitriptyline, imipramine, doxepin a. Watch for risk of torsades de pointes, esp with methadone - Antiepileptics -Gabapentin, Carbamazepine*, phenytoin* - Clonidine - Topical agents - capsaicin, lidocaine patch, topical NSAIDs, EMLA - Muscle relaxants - baclofen, tizanidine, cyclobenzaprine a. Avoid benzodiazepines, methacarbamol, carisoprodol, chlorzoxazone - Interventional procedures - more helpful for acute than chronic pain but some benefit for chronic pain

Sexuality in OK

- No OK state law requiring sex education in public schools a. Local school boards decide - In this class: people differ in sexual attitudes and behaviors that you don't know about--be sensitive with comments a. Some more conservative, some more liberal

Asexuality

- No sexual attraction to M or F partner a. 1% of British sample of >18,000 people (Bogaert, J Sex Res, 2004) - Study of >1,000 asexuals compared to non-asexuals a. Less desire for partner, lower arousal & excitation b. No difference in sexual inhibition or desire to masturbate - No ↑psychopathology

Treatments of Erectile Disorder

- Nonbiological treatments a. Set stage for erection: stimulation in relaxed circumstances--facilitate reflex (can't "will" it) b. Sensate focus: female stimulates erection c. Male focuses on erotic sensations without performance demands (refrain from coitus) d. Woman straddles, inserts penis in nondemanding way e. Work toward nondemanding thrusting, and eventually thrusting to orgasm f. Important: avoid demand for "quality performance" g. Difficulties if can't abandon self in "here & now" pleasure, or if he is too self-critical (spectatoring)

Voyeuristic Disorder

- Person >18 years is sexually excited by watching sexual acts or nudity in non-consenting persons ("Peeping Toms") a. Occurs > 6 mo. And causes distress or impairment b. Excludes heterosexual activity, strip clubs c. Excludes normal sexual curiosity at puberty - Lifetime prevalence (highest): up to 12% in males, 4% females - May lead to legal prosecution a. Local laws determine what is acceptable and what is criminal voyeurism - Often leads to shame, loneliness, and sexual frustration

Transvestic Disorder (Cross- Dressing)

- Person cross-dresses for sexual gratification for >6 mo. - Must cause distress or impairment - Prevalence: <3% of men are aroused by cross-dressing - Cross-dressing a male condition (society lets females dress as men) a. Most are heterosexual, happy with gender identity 1. Transvestitism ≠ gender dysphoria (only a few) 2. Often have preferred female clothing b. As physician, be kind to people 1. Allow patients to undress in private 2. Don't appear shocked if patient cross-dressed under street clothes

Sexual Masochism

- Person is sexually aroused by having denigrating things done to self--humiliated, beaten, bound, restrained in cages, made to suffer a. Lasts >6 mo. and causes distress or impairment b. Prevalence in US unknown; more common among men c. Masochist has no excitement or feelings without pain or punishment - Medical risk: accidental death through asphyxiophilia (aroused by restricting breathing) - Leopold von Sacher-Masoch: 19th century novelist whose characters received pleasure from being abused and dominated by women

Evaluation of the patient

- Obtain a pain history and assess the impact of pain on social, occupational, physical, and psychological functioning - Review previous diagnostic studies and medical records - Review medical, psychiatric, and substance abuse history and assess coexisting diseases or complications - Conduct a directed physical examination

Oklahoma in news

- Oklahoma a leader in abuse of pain-relievers. - Oklahoma has six of the 15 regions in the country with the highest rates of nonmedical pain-reliever use, according to a new report.

Genito-Pelvic Pain/Penetration Disorder Complaints, risk factors, & rule out physical causes

- One of most common Ob/Gyn complaints - Risk factors for the mental disorder a. Sexual or physical abuse may predict b. May have history of vaginal infections with pain persisting after treatment c. Psychological factors: unresolved guilt (negative attitudes or beliefs about sex), anxiety, sexual trauma - Rule out physical causes a. Most common cause: inadequate lubrication (older F) 1. foreplay or artificial lubrication may help b. Vaginal infections or STD's c. Allergic reactions to spermicides or latex in condoms d. Pain with deep thrusting may be due to : 1. endometriosis 2. pelvic inflammatory disease (PID) 3. structural abnormalities (tipped uterus, relaxation of pelvic muscles from age or childbirth, ↓lubrication)

Clinical Picture: Stimulant Intoxication

- Onset a. Intanasal effects within minutes (5-15) b. Smoking effects within seconds - Acute Intoxication a. Euphoria, hyperactivity (motoric & verbal), hypersexuality, agitation b. Insomnia, anorexia c. Persecutory (paranoid) delusions, hallucinosis (A/V/T), d. Delirium rare except in very high doses e. Stereotyped movements (skin picking, teeth grinding) f. Elevated BP, HR, temp, rigidity, seizures - Chronic use - tolerance to euphoria & positive effects but anxiety, agitation increase

Opioid Use Disorder: DSM-5

- Opioid use leads to psychosocial dysfunction >2 in last 12 months: a. Tolerance - Need more to get same effect b. Withdrawal - flu-like syndrome c. Loss of control d. Unsuccessful efforts to cut down e. A great deal of time spent using/obtaining substance f. Giving up social/occupational activities g. Use despite knowledge of consequences - With or without physiologic dependence (tolerance/withdrawal) - Once meet criteria for use disorder, always have that diagnosis.

Male Hypoactive Sexual Desire Disorder

- Persistent absence or deficiency of sexual fantasies and desire, considering patient's age and life circumstances - Lasts > 6 months and causes distress a. Not due solely to another medical or mental disorder or substance b. Often associated problems of arousal or orgasm 1. Specifiers: Generalized vs situational Lifelong vs acquired Mild, moderate or severe

Genito-Pelvic Pain/Penetration Disorder

- Persistent difficulties with 1: a. Vaginal penetration with intercourse b. Marked vulvovaginal or pelvic pain with intercourse or attempts c. Marked fear or pelvic pain anticipating or during vaginal penetration c. Marked tensing of pelvic floor muscles during attempted vaginal penetration - Lasts 6 months and causes distress - Not due to other mental disorder, severe relationship distress or stressors, substance or other medical condition a. Specifiers: Lifelong vs. acquired Mild, moderate or severe

Female Orgasmic Disorder

- Persistent difficulty achieving orgasm or reduced orgasmic intensity a. Sexual excitement phase normal b. Lasts 6 months & causes distress c. Not due to nonsexual mental disorder or severe relationship distress, substance or medical condition - What's considered decreased orgasm? a. Stuck in plateau phase of sexual cycle b. Occurs approximately 75-100% of time c. Adequate stimulation must be present 1. For many women, clitoral stimulation necessary 2. A few women always experience orgasm during penile-vaginal intercourse

Male Erectile Disorder

- Persistent inability to maintain erection until completion of sexual activity - Who has E.D.? a. Increase with age, especially after age 50 b. 2% < 40 have frequent erectile problems c. Age 40-80: ≈20% have some problems d. 40-50% of men >60 have significant erectile problems e. Some remit over time - Etiological factors a. Transient problems common with fatigue, alcohol, anxiety about impressing new partner b. ↑ risk: age, smoking, lack of exercise, diabetes, ↓desire c. Performance anxiety often a vicious cycle 1. Lack of sexual skills d. Quality, intensity of relationship important e. Guilt about sex or illicit sex

Clinical presentation of acute HIV infection (Acute Retroviral Syndrome)

- Present in 40-90 % of individuals. - Usually appears 2-4 weeks after exposure, but can present within a few days. - The acute illness is nonspecific and mononucleosis- or flu-like. - A morbilliform rash (also described as maculopapular), usually involving the trunk, occurs in 40 to 80 % of persons. - Symptoms last a few days to more than 10 weeks, but the typical duration is less than 14 days.

Premature Ejaculation Prevalence & Risks

- Prevalence a. Internationally: >20-30% of men aged 18-70 report concerns b. With definition (within 1-minute of penetration), only 1-3% would be diagnosed c. May increase with age, but sexual experience helps - Risks a. More common with anxiety disorders, esp. social anxiety b. Associated with thyroid disease, prostatitis, drug withdrawal (i.e., opioids)

Female Orgasmic Disorder prevalence & risk factors

- Prevalence a. Ranges from 10-42% b. Varies with culture, duration, symptom severity c. 10% of women don't experience orgasm throughout their lifetime - Risk factors a. Anxiety, concerns about pregnancy b. Physical & mental health c. Gender role expectations & religious norms, guilt d. Sometimes performance anxiety e. Relationship problems

Delayed Ejaculation: Epidemiology & Course

- Prevalence: <1% of men - More common in older men - Risk factors a. Age-related loss of sensory nerves and decreased sex hormone secretion, esp. over age 50 - Treatments a. Medications: (not FDA approved) Amantadine, buspirone, cyproheptadine b. Psychotherapy 1. Address relationship issues 2. Reduce performance anxiety, enhance sexual excitement

Alcohol Effects on Neurons (apoptosis & cell death)

- Process of programmed cell death. - Alcohol exposure enhances or modifies apoptosis, resulting in more extensive cell death than what was biologically programmed. - Cells that form connections become strengthened and don't die. - This is a competitive process and those that do NOT form connections will die...sort of a programmed cell death (apoptosis). - Chemicals called trophic factors enhance connectivity.

Risk Factors of Alcohol Use among Older Adults

- Psychological Problems, particularly anxiety - Older adults who are withdrawn, isolated, impulsive, and hypersensitive - Stressful events - Stressful environmental setting - Culture considerations

Pedophilic Disorder

- Recurrent sexual urges and acts toward prepubescent kids (usually < age 13) by someone at least 16 years old and 5 years older a. Not for late adolescent having sex with 12 or 13 year old, or 15 year old with 10 year old b. Not for politician having sex with 21 year old intern - Prevalence: 3-5% of males, less in females - Victims of pedophiles (estimates) a. 20% of all females and 15% males have been victims of pedophile

Consultation

- Referral to a specialist in pain medicine may be warranted depending on the expertise of the practitioner and the complexity of the case - Referral to an addiction specialist is often indicated for patients with a history of addiction or substance use disorder - Referral to a psychiatrist or psychologist may be indicated in cases of significant psychiatric comorbidity

Paraphilic Disorders: Your Role as a Physician

- Reporting: a. Pedophiles: sexual abuse of kids must be reported by law b. Harm of nonconsenting adult: consider Adult Protective Services - For non-harmful paraphilias: a. As a professional, be compassionate b. You may have different beliefs about non-harmful paraphilias c. Refer to someone who can help without compounding the problem 1. Most with paraphilic disorders are in some distress about condition - Intervene when people are abused, coerced

Intro to HIV

- Retrovirus - Targets CD4+ T-cells and macrophages - Lives and multiplies inside of cells a. Latent (dormant) in resting cells b. Destroys active cells

Sexual Sadism

- Sadist is sexually stimulated by creating physical or psychological suffering in non-consenting people a. Males>females b. Prevalence: <10% of jailed sex offenders in U.S. c. May co-occur with antisocial personality disorder, sexual masochism, substance use disorders - Named after Marquis de Sade--18th century French author repeatedly imprisoned for violent sexual acts against women

Characteristic Developmental Sexual Behavior Pattern

- Self-exploration--genital manipulation a. begins in infancy (Piaget's sensorimotor) - Other exploration a. "I'll show you mine if you show me yours." - Masturbation a. Earliest sexual experience of pleasuring self b. Mutual masturbation c. Kinzie studies: 60% pre-pubertal males - Beginning adult patterns - Full sexuality with emotional attachments a. Social Relationships Between the Sexes - Stages of Pubertal Development

Sexual Issues: Your Role as a Physician

- Sex is a normal (pleasurable) biological function - Trusting patients will bring their sexual issues and problems to you a. Some are of an emotional origin b. Some are of a biological origin c. Some involve different sexual preferences d. Some have practices which may be distressing to them or to others - Compassion & role-modeling open communication is important for effective physicians a. Referral for additional help b. Must report abuse

Heterosexuality

- Sexual act between 2 people of opposite sex, regardless of whether there is an emotional attachment - Primary conditions for heterosexual development: a. Gender identity in which person's core sense of self is consistent with genital sex b. Developmental drive toward opposite sex in mid to late adolescence c. Parents and adults do not suppress youth's interest in opposite sex - Modal age of first coitus: males age 16; fem. age 17

Sexual Dysfunctions: Why Study?

- Sexual dysfunctions are extremely common a. 40% of women and 30% of men have experienced some form b. 50% of U.S. couples have a sexual problem at some time c. The primary care physician is the first to evaluate - Good sexual history is important Is there anything you would like to change about your sex life? Have there been any changes in your sex life? Are you satisfied with your present sex life? Are you sexually active? Do you practice safe(r) sex? Be sensitive & nonjudgmental; consider patient's age

Paraphilic Disorders

- Sexual urges and fantasies toward nonhumans, children or nonconsenting persons, or causing real suffering of self or partner a. Disrupt loving bond between 2 people b. Disturbing to the person and/or others around them (mental disorder) c. You may recognize them in ERs or practice d. Some classified as criminal offenses - Demographics a. >Onset often before age 18, rarely > 50 yrs 1. Peak at ages 15-25, then decline - Often > 1 paraphilias

Fetishistic Disorder

- Sexual urges involving non-living objects or nongenital body parts (>6 mo) a. Must be linked with distress or impairment b. Examples: shoes, men's and women's underwear, feet, toes, hair c. Object may be used as a sexual partner by masturbating with it d. Not part of cross-dressing or for tactile stimulation (vibrator)

Documentation

- Specific documentation on the following areas should be maintained: A. Evaluation B. Diagnoses (Including reasons for prescribing opioids in not obvious from the diagnosis) C. All prescriptions written D. Overall plan to manage pain E. Consultations received F. Written instructions to patient, the patient's consent, and agreement with the patient

Treatment of Premature Ejaculation

- Squeeze technique a. Easy and non-invasive b. Man gets erection c. When M feels close to ejaculation, F takes penis between thumb and 1st 2 fingers, squeezes tightly for 20 seconds at level of frenulum until M can't feel impending orgasm d. The couple continues this, with male increasing time he can hold ejaculation e. Practiced 3-4x/night for 2-3 weeks, male learns control - Medications: antidepressants affecting serotonin inhibits ejaculatory reflex--SSRI's (prozac) - Untreated can→impotence from performance anxiety

Opioid Trial: <90 days

- Start with short-acting and later convert to longer-acting equivalent - Maximum dose MED: 90-120 mg/day a. Take a breath at 90 mg. - Measure/record 4 As: Analgesia Activity Adverse effects Aberrant Behavior - Avoid benzodiazapines & other sedating drugs - ~10% dose reduction Q1-2 wks - Monitor UDS: If UDS+, begin immediate referral and treatment for possible addictive disorder. - Utilize as many non-opioid interventions as possible.

Advising Appropriate Action:

- State your Concern - Be specific about patterns and health risks - Advise - a. Stop Drinking altogether 1. If there is substance use disorder, history of failed attempts to cut down, contraindicated medical condition, taking medication that interacts b. Cut down - If there is drinking above recommended levels but no evidence of substance use disorder - Make a Plan of Action - a. If no substance use disorder: 1. Recommend specific limits 2. Ask patient to set specific drinking goals 3. Provide education materials b. For suspected substance use disorder: 1. Refer for additional evaluation/treatment 2. Involve patient in referral decision 3. Discuss treatment options/services

Are older people interested in sex and are they having sex?

- Studies are limited with poor response rate - Swedish study (Men) a. 98% had interest 50 to 59 b. 72% had interest 70 to 80 - US Study (3000 people) a. 59% of 75 to 85 thought it was important - UK study (44 people) a. Those older than 70 were less interested but very interesting qualitative data

Other Biological Treatments of Erectile Disorder

- Testosterone therapy for deficiencies (I.M.) - Medications (older) a. Injections: best for nerve rather than vascular problems 1. Alprostadil (Caverject, Edex)--relax muscles around blood vessels in penis, allowing vessels to bring more blood into penis, increasing vasocongestion => erections>1 hr without stimulation & a urologist's unusual demonstration at medical convention 2. Phentolamine (Invicorp): erections with stimulation - Suppository gel inserted in tip of penis by applicator: alprostadil--65% success rate - both Alprostadil & Phentolamine are muscle relaxants

Birth and Postnatal development -

- The Biology of Social Structures = Environments = Society

Pedophilia

- The pedophile a. Usually afraid of sexual relationship with adult b. Pedophile may be familiar to victim c. Alcohol often involved, decreasing inhibitions d. Usually fondles, sometimes oral sex, occ. penetration - Effects on child victim a. Often reflex stimulation, later guilt and mistrust in relationships b. Confusing to child, especially if parent reacts strongly (may get message, "What feels good is bad.") - Your role as physician a. You must report child sexual abuse b. Behave professionally, perform calm assessment and intervention

Clinical Clues Suggesting Alcohol Use in an Older Patient

- Therapy is not working for a normally treatable medical illness (e.g. hypertension) - Insomnia or chronic fatigue related to poor sleep - Diarrhea, urinary incontinence, and weight loss or malnutrition - Complaints of anxiety (related to undiagnosed withdrawal), with frequent use of or request for anxiolytics, sedative, or hypnotics - Unexplained postoperative agitation, anxiety, confusion, or new-onset seizures (suggesting withdrawal)

Patients/Doctor Shopping

- Things to do to intercept a. Talk with family members b. Computerized medical/prescription records c. Collaboration with pharmacists

Practice Guidelines for Treating Older Adults with Substance Abuse Problems

- Treatment Impairment Protocol Series (TIPS) #26: Substance Abuse Among Older Adults (SAMHSA) a. Emphasize age-specific, group treatment, supportive (not confrontive) b. Attend to negative emotions: depression, loneliness, overcoming losses c. Teach skills to rebuild social support network d. Employ staff who are experienced in working with elders e. Link with aging services, medical services, institutional settings f. Slow the pace and content of treatment g. Create a "culture of respect" for older clients h. Broad, holistic approach to treatment recognizing age-specific psychological, social and health aspects i. Adapt treatment as needed in response to client's gender

The Law and Sexuality

- U.S. Supreme Court (2003): Sex between consenting adults OK - Oklahoma law upheld before 2003: Restrictions on common sexual behaviors different from penile-vaginal intercourse between married persons - No OK laws on discrimination for gender identity or sexual orientation - OK law forbids recognition of same-sex marriage; constitutional change defined marriage (2004) a. OK for unmarried adults to adopt kids regardless of sexual orientation

Disease Progression

- Variable time course - Majority (60-70%): median time from infection to AIDS is 8-12 yrs - 10-20%: rapid progressors - 5-15%: slow progressors ~1%: long-term non-progressors

Surgical Treatments : Erectile Disorders

- Vascular: arterial bypass to reroute blood around blocked vessels or for structural defects - Penile implants: irreversible, so only refractory cases a. Malleable: silicone rubber rods in permanent semi-rigid position- can hang close to body b. Inflatable: more extensive surgery - Vacuum pumps a. Vacuum constriction device (ErecAid) b. Cylinder connected to hand-operated vacuum pump c. Side effects: bruises and pain; semen trapped in urethra until rubber bands released, infections in some

Teen sex

- by age 19, 7 of 10 teens have had sexual intercourse

Medications for Stimulant Dependence

- cocaine - amphetamine

Making it more addictive

- different forms - sell it and advertise it through sex - bring it through gambling

Natural sources of choline

- eggs, cabbage, beans, peanuts

Ambiguous gender role behaviors

- either on the Male side or on the Female side - That is, more Male-typical or more Female-typical (the "default" behaviors)

FASD in other countries

- incidence differs significantly among cultures, countries and individuals.

Clinical Characteristics

- late onset - early onset

Ethanol

- may alter brain cell 'function' during development. - exposure to progenitor nerve cells, which are forming new nerve cells, may affect the formation of the new daughter cell, called a neuroblast. - The 'birth' of the neurons appear to be exquisitely sensitive to ethanol exposure, indicating that alcohol may affect neurogenesis. - Each cell during development divides by mitotic division to form a 'daughter' cell. - process and timing is a critical event. - number of divisions during the formation of the nervous system is astronomical given the number of nerve cells found in the newborn brain and the period of time those cells are formed.

Neglect - Environment Matters

- neglect leads to excessive pruning leading to neural and behavioral deficits. - Early neglect can damage brain development and lead to atrophy. Bucharest Early Intervention Project studies this a unique way. Many children raised in orphanages in Romania are at dramatically increased risk for a number of social and behavioral abnormalities such as disturbances of attachment, inattention/hyperactivity, externalizing behavior problems, and a syndrome that mimics autism Figure description Think about our brain like a muscle - the more one uses it the stronger it becomes.

Alcohol Effects on Neurons

- neurogenesis => Growth of the nervous system during development is dependent upon appropriate cellular division. Cells that form specific parts of the brain are 'born' as specific times during development.

Fetal Alcohol Syndrome

- now is recognized as the leading known cause of mental retardation in the United States, surpassing spina bifida and Down's syndrome - concluded that FAS, ARBD and ARND are completely preventable and represent a "major public health concern." - Diagnosis based upon history, physical features (facies), growth retardation, and CNS abnormalities.

People who are prone to addiction

- probably have a different receptor structure for some neurotransmitters in the midbrain. - There also may be a higher density of certain receptors or different connections between neurons. - The exact predisposing factor has not been isolated with certainty, however, it has been clearly demonstrated that there is marked variation among our population with regards to predisposition to addiction.

Co-morbid Diagnoses

- psychological - physical

Plasticity

- refers to a nerve cell's ability to grow back and re-establish meaningful connections after it is damaged, such as by trauma - Once maturation occurs, most neurons are post-mitotically static and less able to regenerate their function - Alcohol exposure during development will decrease the ability of the nervous system to regenerate.

SO

- sexual orientation romantic or sexual preferences for or attraction to a give sex

Moderate Drinking: Benefits?

-Possible association with lower rates of coronary heart disease in older people a. Diet/exercise likely to be as effective b. Vulnerability to alcohol-related problems - May be associated w/greater social contact a. However some people drink alone - Abstainers should not be advised to begin drinking in order to gain these "benefits

Summary - Gender Identity

. Complex reduction of overall Identity 2. Affected and effected by Androgen effects - or lack of them - prenatally 3. Affected by other factors, most likely, but... ? Sex Chromosomes? Postnatal minipuberty? Environment? 4. May not be congruent with Gender Role behaviors 5. Can really only be known to the Self

Normal Aging

A gradual slowing - more time needed for arousal and climax.

Common specialties of distressed physicians

1. surgery 2. anesthesia 3. hospitalist

Prognosis

1980 - 20% suicide rate among physicians disciplined 1987 - 1.5% suicide rate, 75% improved, following change to rehab model 96% improved with ongoing monitoring 64% improved without monitoring With PHP's Suicide down to 1% Suicide

The 80's

1983 Isolation of HIV-1 by Françoise Barré-Sinoussi and Luc Montagnier (2008 Nobel prize) 1985 FDA approves first commercial HIV antibody test 1986 HIV-2 identified in West Africa 1987 AZT - first approved antiretroviral

Early 90's

1990 Ryan White Care Act passed 1992 Magic Johnson reveals HIV infection 1993: Concorde Trial: no difference in 3yr clinical endpoints with early vs. deferred AZT 1994-95: ACTG 076: AZT reduces mother-to-child transmission of HIV ACTG 175, ZDV/3TC Era of combination ART therapy begins.

Undertreated Pain

1995 - SUPPORT study results published in JAMA 1998 - FSMB new guidelines for treating pain 1999 - Pain as 5th vital sign 2000 - JCAHO unveils pain management standards

Prevalence - SubstanceDisorders

10% - 15% Lifetime prevalence (similar to population at large) Ratio - Drugs to Alcohol may be higher than general population but alcohol is still most common substance abused by physicians

Medical Schools & Sexuality in Curriculum

1966: 4% of medical schools had courses in human sexuality 10 years later: 96% had courses A medical school survey in 1960's: 85% of faculty endorsed masturbation=> insanity Now: Survey of 176 medical schools in US & Canada: Small content of lesbian, gay, bisexual and transgender-related issues But quality varied

The New Treatment Era

1996:The Beginning of ART/HAART

Frequently Endorsed Reasons for Using:

2637 6th-12th grade students from 5 different school districts in rural Oklahoma (Novacek, Raskin, Hogan) (Used N=779) Top 5 most frequently endorsed reasons for using: Because I was depressed 49.9 % To escape form my problems 46.9% To relax 46.4% To have a good time 45.6% To see what effect they would have 42.6%

National Household Survey on Drug Use and Health

35% used alcohol in the past month 50% 60 and older 7% reported current binge drinking (5+ drinks on the same occasion on at least 1 day in the past month) 2% reported current heavy drinking (5+ drinks on the same occasion on each of 5+ days in the past 30 days)

How many ?

5.5% of pregnant women used an illicit drug during pregnancy

What is Denial

A primitive defense mechanism Subconscious It always suprises me when people get upset about an addict or ALCOHOLIC lying to the them. What else would you expect. It takes a lot of work 'Often the best & brightest

Gender, Gender Identity, Gender Identification (Gender Role, Expression), Sexual Preference (Orientation): 3 cases

A. Girl's mother dies when child young Girl models after father and brothers, with external masculine behaviors and appearance But, she knows she's female and she has sexual preference for females... A. Gender: F; Gender identity: F; Gender identif. (Role): M; Sexual pref. (orient.): F B. Boy raised in single parent home with no male role model Has feminine appearance, interests But he knows he's male, and dates girls... B. Gender: M; Gender identity: M; Gender identif. (Role): F; Sexual pref. (orient.): F C. Boy raised with clear male role model Behaviors & dress are masculine, wants to date males But he believes he's a woman trapped in male body... C. Gender: M; Gender identity: F; Gender identif. (Role): M; Sexual pref. (orient.): M

DSM-5 Cannabis Withdrawal

A.. Cessation of cannabis use that has been heavy or prolonged B. 3 or more developing within several days of stopping use: Irritability, anger, aggression Nervousness or anxiety Sleep difficulty (insomnia) Restlessness Depressed mood At least 1 physical symptom that causes significant discomfort: stomach pain, tremor, sweats, fever, chills, HA C. The symptoms in B cause clinically significant impairment in social, occupational, or other important areas of functioning D. Symptoms not better accounted for by another disorder or GMC

OHPP We Work with Docs who are:

ADDICTED to "Something" DISRUPTIVE (Distressed Physician) BOUNDARY ISSUES FITNESS FOR DUTY

Symptoms of Substance Abuse

AOB Change in Behavior Cognitive Impairment DUI Disruptive Withdrawn Unavailable Fatigue Missing work Missing drugs "Where there's smoke there's fire - Intrestingly—ability to practice is last to go—The first is relationships

What is Recovery?

Abstinence Dopamine Restoration? Recovery behaviors Rest Food Intimacy Exercise Spirituality Etc.

Overview: Facts

Abuse of alcohol, illicit drugs, and prescription drugs among adults 60 and older is one of the fastest growing health problems facing this country. By the year 2020 the number of older adults in need of substance use treatment will double. Why? Adults age 65 and older consume more prescribed and over-the-counter medications than any other age group.

Using Opioids for Chronic Pain

Acute pain - Use short acting agents only! NO Methadone, Oxycontin®, MS ER, or Fentanyl Patch Chronic pain - Use short or long-acting; seek lowest morphine equivalent dose (MED) combination

How to understand addiction (cont)

Addiction involves all dimensions of who and what we are -it affects your entire life; You can't just keep it part-time or hidden away -drug addiction will eventually reshape your entire being biologically, cognitively, socially, and existentially.

Why Opioid Replacement Therapy?

Addiction is a chronic, relapsing illness that needs ongoing treatment. Possible altered neurobiology Reduced use, reduced crime Oral/SL - stop injection drug use Improves health & immune function Stops withdrawal Improves social functioning

Summary of Neurobiology

Addiction occurs in 3 stages: Binge/Intoxication - classic reward pathway Withdrawal/Negative Affect - decreased reward neurotransmitters Preoccupation/Anticipation - new set-point in anti-reward pathway & craving: Glutamate Norepinephrine Stress response & CRF Neurobiological changes may be permanent.

Neurobiology of Addiction

Addiction occurs in 3 stages: Binge/Intoxication - classic reward pathway Withdrawal/Negative Affect - decreased reward neurotransmitters Preoccupation/Anticipation - new set-point in anti-reward pathway & craving: increase in Glutamate increase in Norepinephrine Stress response & CRF

Step 5:

Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

Not Adult Treatment

Adolescents in treatment vs. adults Family School based component Developmental tasks Motivation and family support = stay in treatment Types of treatment: outpatient; intensive outpatient; inpatient; 12-step; therapy: group, individual, family

Substance Problems Like Other Chronic Conditions

Adolescents with substance use problems similar to adolescents with other chronic conditions such as diabetes, asthma, hypertension

Development of new neurons:

Adult cerebral cortex - 1010 neurons Adult cerebellar cortex - 1011 neurons Rate of generation: >450,000 neurons/minute over the 9 month period of development

New Users of Illicit Drugs 2011

America constitutes 4.6% of the world's population but consumes 80% of the global opioid supply, 99% of the global hydrocodone supply.

Addictions Psychopharmacology

Alcohol Nicotine Opiates Stimulants

Alcohol Effects on Neurons (Synaptogenesis)

Alcohol effects on: Neurotransmitter Receptors GABA receptors Signal Transduction Mechanisms G proteins, cAMP, etc Membrane stability

Lori was a 1 year old infant who was removed from her home for neglect. She had severe rash from her diaper being unchanged for long periods of time. Her motor milestones were delayed. She was left in her crib for long periods of time. She barely made eye contact, had several repetitive behaviors. Mother was found to have been passed out by her. Birth father had no involvement with the child and barely even visited her. Both parents abused methamphetamine. Mother vehemently denies abusing drugs when pregnant.

Among the problems found in these children are increased vulnerability to visual problems, inadequate fine motor coordination, heightened levels of motor activity, and attention deficits, particularly in structured interactions

'Safe' Levels

An average of less than 1 drink per day has been demonstrated to result in: Enduring growth retardation Neurobehavioral deficits Organ malformations

Prevalence of HIV

An estimated 120,000-160,000 women in the United States are living with HIV. Many of the women are unaware that they are HIV-positive. Each year, about 6,000-7,000 of these women give birth.

Endocannabinoids

Anandamide AEA 2-AG Olvanil

Psych co-morbidities

Anxiety disorders Depression Cognitive impairment Schizophrenia AntiSocialP Disorder

Who or What is a Disruptive Physician?

Any Behavior That Creates A Hostile Work Environment

Network Therapy

Appropriate when loss of control is a major factor in overall recovery AND when the patient has an available network of sober family or friends Part of treating team, rather than presenting for "family sessions" Network monitors abstinence, pills taken, etc. & reports to therapist Improves social support and can provide external motivator for abstinence Designed for office setting

Characteristics of Addiction

Compulsion Continued use despite adverse consequences Craving Denial

Loss of Choice

At some point the ability to drink/use responsibly is lost. Once a drink or drug is taken, behavior is unpredictable. "When I drink I can not predict what will happen." After Crossing an Invisible Line, the ability to choose whether you "use" is lost. The Phenomenon of "Craving" Begins.

Most common symptoms: of Alcohol Withdrawal Syndrome

Autonomic hyperactivity (sweating, tachycardia) - usually an early sign primarily Increased hand tremor Insomnia Nausea or vomiting Transient visual, tactile, or auditory hallucinations or illusions Psychomotor agitation Anxiety Grand mal seizures

Motivational Enhancement Uses

Based on Miller & Rollnick's Motivational Interviewing Useful during engagement process Usually brief interventions (1-4 sessions) Focuses on patient ambivalence, decision making, & commitment to help them progress through the change process Used in multiple psychiatric, addictions, & general medical settings

Twelve-Step Facilitation (basics & core principles)

Basics - Read AA/NA material, go to an AA or NA meeting, & read TSF manual Core Principles Acceptance of the illness of addiction Surrender - Unable to obtain recovery on their own, but there is hope of recovery through a higher power

Signs and Symptoms

Before age 13 1 drug daily or weekly Poly-drug use Academic problems Behavior changes Mood changes Changes in friends, physical appearance, and/or usual activities

2004 CDC CriteriaFunctional 'Abnormalities'

Below average scores on standardized instrument or clinical impression of functional deficit in one of the following domains: General Cognitive Deficits Executive Functions - (working memory of reasoning, task flexibility, and solving as well as planning, and execution. Using past experiences to plan and execute present actions) Motor Functions Attention Deficit/Hyperactivity Social Skills Mental Health Problems Other

Male Erectile Disorder (biological factors)

Biological factors contribute in up to 80%: - Medical/surgical conditions: D.M., M.S., decrease in circulation, spinal cord injuries, transected nerves after prostate surgery, endocrine problems - Age and endocrine problems - Drugs: antihypertensives, antidepressants, benzodiazepines, phenothiazines, opiates, alcohol, long-term cocaine use (almost anything but androgens) - Assessments: sleep studies show healthy men have erections during REM, every 90-100 minutes (nocturnal penile tumescence, NPT)

Alcohol Withdrawal Syndrome Treatment

Benzodiazepines or Antiepileptics (such as Carbamazepine, Valproic Acid)

Adolescent Substance Use

Bingeing or opportunistic use Legal to illegal Adolescent use compared to adult Correlation between use and many emotional and behavioral problems (SAMHSA)

First Language of Sexuality

Biologic and intense for the young

Alcohol Exposure

Biomarkers: Gamma- glutamyl transferase Carbohydrate deficient Transferrin 39- 72%

Guidelines for HIV positive pregnant women

C-section. Antiretroviral drugs now recommended for all HIV infected women, regardless of HIV RNA levels. May delay the treatment till 10-12 weeks.

Cannabinoid Receptors

CB1 - CNS (basal ganglia, limbic system, hippocampus) CB2 - PNS & immune system Maybe a 3rd receptor?

Screening Tool

CRAFFT Questionnaire C- Have you ever ridden in a CAR driven by someone (including yourself) who was "high" or who had been using alcohol or drugs? R- Do you ever use alcohol or drugs to RELAX, feel better about yourself, or to fit in? A- Do you ever use alcohol or drugs while you are ALONE? F- Do you ever FORGET things you did while using alcohol or drugs? F- Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? T- Have you gotten into TROUBLE while you were using alcohol or drugs: Two or more "yes" answers suggests a significant problem.

Step 2:

Came to believe that a Power greater than ourselves could restore us to sanity.

Solutions to Scams (2)

Carefully document in progress notes the rationale, diagnosis, anticipated time course, and symptom endpoint when initiating a controlled drug prescription Consider a prescription refill flow chart Establish a cross coverage prescription policy

How HIV is NOT Transmitted

Casual contact (hugging, shaking hands) Coughing/sneezing Sharing food or utensils Dry kissing Donating blood Mosquitos and other insect bites

Alcohol Effects on the Brain: Summary

Central Nervous System or Neurobehavioral Disorders Structural Cell death and incorrect migration Regional brain development failures Failure of nerves to 'link up' Decrease in NS regeneration Neurological effects Functional effects

Family Role

Changes the entire family system Assume dysfunctional roles Family unit: cohesive vs. un-cohesive

Impaired Professionals

Chemically Dependent Disruptive Physicians Elderly- Fitness of Duty Mental Disorders Illegal Activities Behavior Problems(Process Addictions) Boundary Issues/Predator? The FLU ?? Cancer Tx's ??

Suddenness of birth, postnatal sex hormone surge (M)

Childhood development - activations of and adaptations to environments

Cocaine exposure

Children may suffer from learning disabilities, affect regulation and behavioral problems and other neurologic issues that may become manifest in later years.

The Challenge: Finding A Potential Partner

Choosing appropriate partner by elimination: All possible partners = 100% of people Eliminate non-preferred sex = 50% Exclude inappropriate age = 25% left Exclude inappropriate family, race, religion, national origin = 15% left Exclude different socioeconomic background & lifestyle = 7% left Selective person you find attractive & compatible ......Who's left?

Putting It All Together

Chronic pain - neuroplastic changes, genetics, & sensitization => hyperalgesia Opioid Use Disorder (DSM-5) increase in Glutamate increase in Norepinephrine Altered HPA Axis Altered opioid receptors History of mental illness, age <65 Treatment: If both disorders are present, treat them simultaneously using a biopsychosocial model.

Binge/Intoxication: Reward Pathway and More

Clinical Picture: Acute Reward Neurotransmitters: Dopamine Opioid Peptides GABA Serotonin Endocannabinoids

Antiretroviral Therapy: Adverse side effects

Common side effects: GI intolerance - nausea, vomiting, diarrhea Rash (tenofovir, efavirenz) Renal failure (Tenofovir) Neuropsychiatric including depression (Efavirenez, Rilpirivine) Lactic acidosis (NTRIs) Hypersensitivity reaction (Abacavir - HLA B5701) Liver toxicity/hepatitis/hyperbilirubinemia (many) Hyperlipidemia (efavirenz, lopinavir, ritonavir) Lipodystrophy (NRTIs) Bone marrow suppression (Zidovudine) Painful neuropathy (D4T) Pancreatitis (DDI, D4T) Birth defects (Efavirenz)

Testing after birth

Confirmation of fetal exposure may be accomplished by testing of urine. Analysis of meconium and/or hair provides a longer window of fetal drug exposure, but these testing methodologies are generally restricted to research laboratories

Cocaine: Vasoconstriction

Congenital anomalies in a pattern of "fetal vascular disruption" After birth: Necrotizing enterocolitis, Bowel perforation, Arterial thrombosis, Hypertension, Myocardial ischemia.

Step 10:

Continued to take personal inventory and when we were wrong promptly admitted it.

Drinking Patterns Among Older Adults Continuous & Intermittent

Continuous versus Intermittent Drinking Continuous: Drinking problem is ongoing Intermittent: Refers to regular heavy drinking followed by a period of abstinence/sobriety (3+ years) Problem drinkers who have been sober for many years are at risk for relapse as they age

Dealing with ScamsPrinciples

Cops vs Docs attitudes No offense, but . . . Learn to recognize common scams Just say no (and mean it) Turn the tables

CBT Treatment Goals

Recognize situations when the individual is most likely to use Avoid those situations when appropriate Implement a range of cognitive and behavioral coping strategies

Why Professionals Use Drugs

Curiosity-It helps my pts, maybe me? Recreation- new or previous hx of use Therapeutic-.ie.-treatment after surgery Relaxation-drink after work Easy access- Anesthesiology Peer pressure Other

A primer on primary infection

Definitions (in order of occurrence): Primary Infection - The first interaction between the host and the virus in which HIV infection becomes established in the host. Acute Retroviral Syndrome (ARS) - A constellation of physical signs and symptoms triggered by the immune response to the virus. Seroconversion - When an infected host develops a specific antibody response against HIV. This typically happens during the acute retroviral syndrome. - Each of these events are grouped together in a single new infection, but sometimes the ARS is not noticed

What About DSD?

DSD occur mostly because of: 1. Inadequate T or DHT exposures 2. Inappropriate T or DHT exposures ? → M or F GI or ?? (is there another sex?): either 1. or 2. leads to so-called "ambiguous" genitalia

Classification of Drinking Practices and Problems in Older Adults

DSM-V `. Substance Use Disorder (no longer a criteria between "abuse and dependence") Two or more criteria must be met (2-3 mild, 4-5 moderate and 6+ severe) 2. At-Risk, Heavy, and Problem Drinking

Special Considerations

DSM-V criteria may not apply to elderly making diagnosis more difficult Withdrawal: many elderly (late-onset) alcoholics do not develop physiological dependence Activities: may have fewer activities

Classifying Drinking Practices and Problems Among Older Adults: 11 Criteria

DSM-V: Substance Use (2+) 1. Taking the substance in larger amounts or for longer than the you meant to 2. Wanting to cut down or stop using the substance but not managing to 3. Spending a lot of time getting, using, or recovering from use of the substance 4. Cravings and urges to use the substance 5. Not managing to do what you should at work, home or school, because of substance use 6. Continuing to use, even when it causes problems in relationships 7. Giving up important social, occupational or recreational activities because of substance use 8. Using substances again and again, even when it puts the you in danger 9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance 10. Needing more of the substance to get the effect you want (tolerance) 11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

Toxicology Cannabinoid

Deposited in fatty tissue for long periods after use No known deleterious effects due to slow release of THC Detection in urine - 10 to 30 days Determining time since last use: THC metabolite/THC ratios Passive inhalation (aka second-hand smoke) does NOT produce a positive urine drug test

Medications for Cocaine Dependence

Desipramine - tricyclic antidepressant; mixed results; best for those with depression, antisocial Disulfiram - aversion reaction to cocaine via dopamine beta hydroxylase; caution if still using cocaine Antiepileptics - Tiagabine, Topiramate Block cocaine-induced kindling; small positive trials

Older adults experience

Desire Arousal Climax Recovery

What decreases Denial

Disease Model of Addiction Empathy Physician Health Programs Rehabilitation Focus Confidential Track

DSD

Disorderso f Sex Development (not sexual)

Medications for Alcohol Dependence

Disulfiram - classic flushing reaction from build-up of acetaldehyde by inhibiting aldehyde dehydrogenase; caution in certain populations Naltrexone - opioid antagonist; works best in those with strong family history Acamprosate - effects glutamate neurotransmission; ? efficacy Carbamazepine & Divalproex - antiepileptics; acute withdrawal, irritability, & reduced heavy drinking days Baclofen - GABAB receptor agonist; increases days abstinent but also has some abuse potential

Neurotransmitters involved w/ addiction

Dopamine Endorphins, Enkephalins GABA Norepi, epi Serotonin Acetylcholine

Postnatal Period

During the postnatal period, infants may be inconsolable and tax the tolerance of the parents. Development of effective mother-infant communication is impaired as the infant experiencing withdrawal rejects the mother's attempts at consolation

CDC Criteria (2004)

Facial Abnormalities Smooth philtrum Lip philtrum guide 4 or 5 Thin vermillion Lip philtrum guide 4 or 5 Palpebral fissures 10th percentile or lower Documentation of growth deficits Documentation of CNS or neurobehavioral disorders

Drinking PatternsAmong Older Adults

Early versus late-onset problem drinking - Early onset: longstanding alcohol-related problems, prior to age 40, high probability of psychiatric co-morbidity, continuance of established, abusive drinking patterns. - Late onset: problems began after age 40-50. Appear healthier than early onset. May be drinking in response to loss or life change.

Opiate Exposure

Effects of maternal heroin or methadone use on infants are moderated by the adequacy of prenatal care, obstetric complications, and maternal polydrug use

Examples of disruptive physician

Employs threatening or abusive language, directed at nurses, hospital personnel, or other physicians (e.g. belittling, berating, and/or threatening another individual) Makes degrading or demanding comments regarding patients, families, nurses, physicians, hospital personnel, or the hospital. Uses profanity or other grossly offensive language while in a professional setting.

DRUGS OF ABUSE

EtOH- major substance of abuse Narcotics Stimulants Sedative-Hypnotics Designer Drugs Hallucinogens

How to survive

Evaluation of the patient Treatment Plan and Objectives Periodic Review Consultation Documentation

Intervention/Evaluation

Evaluation vs. treatment Evaluation: style (medical vs. forensic model, inpatient vs. outpatient, psychiatric vs. addiction model, treatment center bias?) Evaluation: should include individual, group, and thorough collateral

Why does the brain like opium more than it does broccoli?

Every known addictive drug interacts in some way with neurotransmitters of the human brain. (Solicit their input regarding which drug matches w/ which neurotransmitter.)

Cognitive-Behavioral Therapies

Evidence-based Etiology of substance use is multifactorial Focuses on reinforcing effects of the substances Individual or Group 12-24 sessions Defining features Functional analysis Skills training

Twelve-Step Facilitation

Evidence-based, manualized, 12 session intervention Techniques used by the therapist to help the patient engage in and maximize their response to 12-step meetings Focuses on AA & NA, but can be applied to other 12-step approaches but is not AA/NA, nor endorsed by them Most residential treatment programs are highly affiliated with 12-step approaches Can help marry the divergent philosophies of the addictions and psychiatric communities For those with dependence, NOT ABUSE

Second Language of Sexuality

Experiences over the lifetime Intimacy, trust, love, friendship, romance and caring.

FAS & the Brain - IQ at 8 yrs

FAS - fetal alcohol syndrome; PEA - prenatal exposure to alcohol; NC - normal control FSIQ - full scale IQ; VIQ - verbal IQ; PIQ - performance IQ

Physiology of Human Sexual Response: Arousal

Females slower (should be kept in mind for pleasure of both) Psychogenic--from brain through spinal cord Multisensory Touch: Vision: Sound: Smell:

Natural Rewards

Food Water Sex Nurture Learning Success

Guidelines

For children born to HIV positive pregnant women Antivirals for the baby for first six weeks after birth.

Appropriate Treatment Strategies

For older adults with an identified substance use problem the consensus panel recommends the least intensive treatment options be explored first including - Brief Therapeutic Interventions - Family/ Friend Intervention - Motivational Counseling

Substance Use and the Adolescent Brain

Frontal lobes - brain vulnerable- pruning and strengthening

Methadone

Full opioid agonist - methadone maintenance clinic only Utilize methadone due to good oral bioavailability and need for once-daily dosing (for opioid withdrawal symptoms). Highly regulated by federal government Gold standard Requires one year of dependence Approved for pregnancy Cannot treat pain adequately in a methadone maintenance clinic.

Psychodynamic Treatment Goals

Gain/maintain abstinence Provide richer understanding of & control of their inner lives Reduce psychological triggers Improve patient self-esteem Improve self-care Improve affect regulation

GI

Gender Identity; (inner sense of being Male or Female)

GR

Gender role - behaviors, attitudes more typical of males or females - (measureable) prenatal, postnatal, child and pubertal expressions of sex - differences in behaviors

Craving Type 2: Relief Craving

HPA Axis - CRF Norepinephrine

Step 12:

Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs

Healthy Drinking Guidelines for 65+

Healthy (no problematic medications) No more than 1 drink per day (NIAAA) Maximum of 2 on any drinking occasion (CSAT consensus panel) Slightly lower for women (CSAT consensus panel) One standard drink is equivalent to: 12 oz beer 1.5 oz hard liquor 5 oz table wine 4 oz sherry or liqueur

Screening for Q & F

How many days/wk do you drink? On a typical day, how many? Maximum per occasion in past month? Define "drinks" Avoid questions like "do you drink?" Clarify terms like "socially" and "occasionally"

Step 7:

Humbly asked Him to remove our shortcomings.

Summary

Impact is multidimensional. Impacts the relationship between infant and parent.

Fissures

Important landmarks: Inner canthus Outer canthus Palpebral fissure

Solutions to Scams

Improve skills to identify chemical dependence Aggressively pursue skills in DDx and management of: Acute vs chronic pain Anxiety Depression Insomnia

Sexual Dysfunctions

In Men: a. Male Hypoactive Sexual Desire Disorder b. Erectile Disorder c. Premature (Early) Ejaculation d. Delayed Ejaculation In Women: a. Female Sexual Interest/Arousal Disorder b. Genito-Pelvic Pain/Penetration Disorder c. Female Orgasmic Disorder In both: a. Substance/Medication-Induced Sexual Dysfunction b. Other Specified Sexual Dysfunction - common problems: => 1/3 men & 4/10 women

Bio-Psycho-Social Factors

In one Philadelphia study: 83% of the women entering drug treatment came from households in which parents used drugs, 67% had experienced sexual assault, and 60% had been physically assaulted

Opiate exposure in newborn

In the newborn period, signs of drug abstinence may mimic other serious conditions such as : Sepsis Meningitis Hypoglycemia Adrenal insufficiency Cardiorespiratory disease

Substance abuse is worse for Women

Increased vulnerability of women to the adverse medical and psychosocial consequences of substance use Advance more rapidly and have more adverse medical, psychiatric, and social consequences "Telescoping" (gender-specific phenomenon.) Due to Bio-Psycho-Social factors.

The Substance-Exposed Infant

Infancy is not just about biology. Research on childhood effects of parental substance use continues to suggest biologic and psychosocial impacts.

Infant - Parent Interaction

Insufficient feedback makes it difficult for the mother to understand her child's needs. The behavior patterns of the neonate reduce the caregiver's responsiveness to the infant and exacerbate the low self-esteem often seen in drug-using parents

Cognitive Signs of Alcohol Use

Intellectual deficits consistently appear on tasks involving frontal lobe activity Perceptual-motor deficits Memory deficits particularly with short-term memory Verbal and arithmetic skills generally remain unimpaired

Spectrum of Clinical Symptoms

Intellectual disability Learning disability ADD, ADHD Poor memory and recall Poor compliance Poor planning and impulsivity Abstraction difficulties

Physician Health Program Component Parts

Intervention Evaluation Treatment Monitoring

Advances in Research

Interventions: - Cholesterol replacement reduces ethanol-induced damage to the embryo zebrafish. - Reduction of ocular defects by introduction of D-SAL at the time of alcohol exposure during gestation. - Choline availability and fetal alcohol spectrum disorders: Nutritional risk factors and potential treatments.

Differentially Diagnosing Drug Seeking Behavior

It is critical that a physician treating chronic pain be able to differentially diagnose drug seeking behavior from legitimate chronic pain sufferers

Preoccupation/Anticipation

Key element in relapse Relapse may or may not be associated with craving Craving type 1/ Reward - environmental cues induce drug use Craving type 2/ Relief - Internal anxiety & dysphoria cause drug use

Solutions to Scams (3)

Know the pharmacology and abuse potential for all drugs prescribed Careful prescription writing and management habits Recognize and deal with scams

Drinking Patterns Among Older Adults

Late vs. Early Onset Continuous vs. Intermittent Binge and Heavy Drinking

Confidentiality and Minors

Legally in Oklahoma minors can self consent if: Married He/she is a parent In the military Emancipated Seeking care for pregnancy, reportable communicable diseases, substance use/abuse All information from any such self-consented medical care is confidential and can only

Treatment

Licensed professional oriented program Program has extensive experience w/ licensed professionals DEA, Med Staff relations, Malpractice insurance, NPDB, HMO's, monitoring, naltrexone, etc. Peer group available for regular contact Physician treatment staff involved Other services: neuropsych, psych, etc. Family program Continuing care

A Society in Pain

Lifetime prevalence: 60-80% Low back pain is the leading cause of disability in industrialized nations. "20th Century Healthcare Disaster

Rates of psychiatric disorders are high

Lifetime rates of abuse among drug-dependent pregnant women are high. Physical (71.3%) Sexual abuse (44.5%) Posttraumatic stress disorder (19%) Rates of abuse remain high for many women during their pregnancies PTSD increases significantly risk of Substance Abuse.

Late onset

Likely female Higher SES Drinks in response to stressors Less commonly FHx+ Cognitive loss less severe, more reversible More tx compliant

early onset

Likely male Lower SES Drinks in response to stressors Commonly FHx+ Cognitive loss more severe, less reversible Less tx compliant

Physical co-morbidities

Liver disease COPD Peptic ulcer disease Psoriasis Malnutrition Risk factor for other problems (gastritis, injuries, pancreatitis, cerebrovascular disease, diarrhea)

Skin Manifestations of acute retroviral syndrome

Maculopapular rash affecting face, neck and trunk Usually individual lesions <1cm Confluence rare

Medications for Opioid Dependence

Methadone - gold-standard; long-acting mu opioid agonist; must be in methadone clinic Buprenorphine - partial mu opioid agonist & kappa opioid antagonist; combined with naltrexone (Suboxone); office-based treatment Naltrexone - opioid antagonist; reduces euphoria from opioids, precipitates withdrawal if taken with opioids Clonidine - reduces withdrawal symptoms only

Step 3:

Made a decision to turn our will and our lives over to the care of God as we understood him.

Step 8:

Made a list of all persons we had harmed, and became willing to make amends to them all.

Step 4:

Made a searching and fearless moral inventory of ourselves.

Step 9:

Made direct amends to such people wherever possible, except when to do so would injure them or others.

Sexual Satisfaction Studies

Married couples report: Most sex Most enjoyable sex Monogamy dominant pattern internationally

History

Medical Boards Developed- Late 1800's Harrison Narcotics Act - 1908 Alcoholics Anonymous - 1935 AMA Resolved: Alcoholism- A Disease - 1956 Boards begin to discipline licensees - 1970's Wellness Programs - 1980's Neurobiology of Addiction - 1990's+

How are Doctors referred?

Medical Practice Act- Requires a medical doctor to report to the Board if there is a prudent basis to suspect that another physician is practicing while impaired due to substance abuse or is habitually drunk. 1. Medical Boards refers after a complaint has been filed 2. Referred by spouse, employee, nurse, hospital... 3. Self-referral

Psychodynamic Treatment

Meet 1-2x per week Typically done as individual therapy Connect current conflicts to past using: Interpretation, clarification, free association, confrontation Insight gained in this therapy can help build motivation for change Can help achieve or maintain abstinence Can be used alone or with other psychosocial treatments Will not "cure" the addictive behavior Can wait 6-12 mo to start or start immediately after acute withdrawal ends

'Life-long' Secondary Disabilities Associated with FASD

Mental health problems—94% Trouble with the law—83% Sexual misconduct—49% (children they can't care for) Disrupted school experiences—61% Problems with alcohol and/or drug use Dependent living and employment for life (joblessness, homelessness) Premature Death

Mental Illness & Addiction

Mental illness (esp. bipolar disorder, ADHD, antisocial personality disorder ) increases one's risk for a substance use disorder. Mental illness should be treated concurrent with addictions treatment, if at all possible. Use narcotics (e.g. benzodiazepines, stimulants) as a last resort. Untreated mental illness can contribute to relapse.

Screening Instruments

Michigan Alcoholism Screening Test-Geriatric Version - MAST-G (Long 24/13/10 questions, focused on drinking over lifetime) (Blow et al., 1992) CAGE (Ewing, 1984) Drinking Problem Index (17 items specific to older adult population) (Finney, J.W., Moos, R.H. & Brennan, P.L. 1991) Alcohol Use Disorders Identification Test (AUDIT) - World Health Organization, 1982 (Saunders, 1993) ADLS, Cognitive Functioning, Depression

Stages of Drug Seeking Behavior

Minor scams for drugs Forging prescriptions and making fraudulent call-ins Self Injury, robbery, blackmail

Effects of Alcohol on the Fetus

Miscarriage Premature Birth Low Birth Weight Development Complications Structural and Functional Abnormalities FASD/FAS

Models of Addiction

Moral Model Moral turpitude Dispositional Disease Predisposition Temperance Model Drug focus Systemic Model Family dynamics Social Model Culture Characterologic Model Character Spiritual Model Spiritual Deficit Public Health Agent & Host

Government Recognizes the Value of Opioids in Treating Chronic Pain

Most are CII --Street drugs are CI New Intractable Pain Legislation More Permissive Regulations by Boards New Attitudes from Narcotics Agents MORE PHYSICIAN AUTONOMY

Group Therapy

Most widely used psychosocial treatment for addictive disorders Especially helpful for prevention & tx of behavioral risk factors Can provide social support, help combat the "peer pressure" associated with addictions, & teach appropriate means of interacting with others

What happens with inutero exposure

Much of the literature on children of substance-using parents is focused on these medical complications.

Medications for Amphetamine Dependence

Naltrexone - some positive studies Bupropion - possibly, for those with lower levels of use Risperidone (?) - second-generation antipsychotic; reduced use in open-label trials Modafinil - a stimulant; controversial but promising results in early trials

Neuronal Responses to Alcohol Exposure

Neurogenesis - neuron 'birth' Migration Growth & Differentiation Synaptogenesis Apoptosis Plasticity

Stimulants (Neurotoxicity & Depressed Interactive behavior)

Neurotoxicity syndrome manifested initially by transient hypertonia, hyperreflexia, irritability, and tremors. Depressed interactive behavior, lability of state, and poor organizational response to environmental stimuli.

Alcohol Withdrawal Syndrome

Neurotransmitter systems involved: GABA & NE Symptoms may appear within hours of cessation or decreasing use of ETOH or sedative-hypnotics. They can last up to 1 week. Symptoms may arise before blood alcohol level has reached zero.

Medications for Nicotine Dependence

Nicotine Replacement Therapy - full nicotine agonists; patches mainstay, supplement with gum/lozenges/inhalers; can combine with bupropion, nortriptyline, clonidine Bupropion - antidepressant that augments NA & DA; reduces craving; 30% quit rate Varenicline - partial nicotine agonist/antagonist; 44% quit rate; don't combine with replacement therapy Nortriptyline - 2nd line but maybe as efficacious as bupropion Clonidine - alpha agonist; reduces withdrawal symptoms; 2nd line

Why are only some babies born with FAS?

Not due to differences in types of alcohol Due to: Amount of alcohol Drinking pattern Maternal genetic factors Fetal genetic susceptibility Co - teratogens/co-factors - nutrition - one out of 3

The "Invisible Epidemic"

Often overlooked because: - Difficult diagnosis: symptoms mimic other common disorders (dementia, depression) - Stereotyping: less likely to detect problems in women, the educated, and those with higher SES - Shame: Reluctance to seek help (private matter) - Ageism: different QOL standards applied to older people

Children with HIV

Of the approximately 15,000 children in the United States who have contracted HIV, resulting in about 3,000 deaths. About 90% contracted the virus from their mothers during pregnancy or birth.

Sexuality and Aging

Often over looked in the Medical Exam Missed opportunity for reassurance of normal changes No information about sexual side effects of medications Failure to recognize sexual dysfunction and recommend treatment possibilities

Romania Study with neglect

One example to illustrate this is the gross brain atrophy in the brains of Romanian orphans. This study compares children ranging in age from 3 to 30 months who are being raised in several orphanages in Bucharest, Romania, with one group of children of the same age removed from orphanages and placed into foster care, and another group of children of the same age who were raised in their home by their parents. By comparing children raised in a typical environment with children raised in orphanages (with a significant amount of social deprivation) and with children removed from the orphanage and then raised in a normal, foster care environment, this study seeks to answer some of the following questions:

Common Complications for the Mother

Opiate addiction : Periods of feeling "high" or "sick" within a relatively brief time. Cocaine Abuse: Increased risk of hypertensive crises, cardiac and cerebrovascular complications, seizures, and a range of psychiatric disorders such as dysphoric agitation. Alcohol Abuse: increased rates of hypertension, cardiovascular mortality, and breast cancer, as well as to fatty liver and cirrhosis, gastrointestinal hemorrhage, and peptic ulcer.

Neonatal abstinence syndrome:Opiates

Opiates, including opium, meperidine, methadone, morphine, and controlled-release oxycodone hydrochloride Because most opiates are short acting, signs of abstinence will develop shortly after delivery (generally within 1-3 days), when the cord is clamped and the infant is acutely deprived of the drug circulating in the maternal bloodstream.

Chronic Pain Treatment Responses

Opioids: 30-50% Tricyclic Antidepressants/Antiepileptics: 30-50% Acupuncture: 10% CBT/Mindfulness: 30-60% Physical fitness: 30-60%

Orgasm/Ejaculation

Orgasm reverses arousal system Lumbar sympathetic stimulation firing rate of .8/second for males and females Sacral parasympathetic inhibition Continuous genital epithelial stimulation for orgasm ("friction and frame of mind") Male thrusting time averages 1-3 minutes Orgasm extreme pleasure & tension reduction

Levels of Psychosocial Treatment

Outpatient services Intensive outpatient Day or Partial Hospitalization Residential/inpatient services Recovery Residence Office setting

Motives for Nonmedical Use of Opioids

Pain relief To get high Reduce anxiety/stress To substitute for other drugs To moderate for other drugs

Facial Features of FAS

Palpebral fissures = eye opening Philtrum = groove between nose and upper lip Epicanthal folds = skin folds covering inner corner of the eye Micrognathia = abnormal smallness of the jaw Microcephaly (small head circumference) is not a facial feature per se, but a central nervous system characteristic.

Buprenorphine

Partial mu opioid agonist, kappa antagonist Partial agonist allows for much lower risk of respiratory suppression if overdose. Poor oral bioavailability but good sublingual bioavailability. Combined with Naloxone to reduce diversion, marketed as Suboxone. Must have extra training & DEA certificate (aka DATA waiver) to prescribe. Can be prescribed in a general physician office setting for detoxification & maintenance treatment of opioid dependence.

Psychological and Sociological Effects

Personality Development Social Learning Cognitive and Moral Development Development of Coping Skills and Self-Esteem

Treatment is Supportive

Phenobarbital may be warranted for seizures. Hyporeactive once the initial irritability subsides. Breast-feeding by a cocaine-using mother is contraindicated. Structured physical contact, including gentle handling with body support, soft social talking, and eye contact without overstimulation

FAS in Adolescents and Adults: Clinical Implications

Poor judgment ----------------Easily victimized Attention deficits -------------Unfocused / distractible Arithmetic disability----------Can't handle money Memory problems-------------Doesn't learn from experience Difficulty abstracting----------Doesn't understand consequences Disoriented ---------------------Fails to perceive social cues in time and space Poor frustration tolerance-----Quick to anger

What are reasons for decreased interest?

Physical Illness and Medications Mental health problems - depression Male Sexual Dysfunction - ED & hypogonadism Female Sexual Dysfunction - decreased desire/arousal, anorgasmia & dyspareunia Lack of partner - either because of loss or health

MD - Malignant Denial

Physicians are the worst, b/c their education makes then think they know everything, they are too smart for there own good

Prognosis Good

Physicians in recovery have a lower malpractice rate Physicians in recovery are valued by peers and patients (increased awareness of addiction, humility, honesty, balance, etc.) 95% success at 5 years with one relapse 90% success at 5 years w/o relapse

Birth and its Changes in males

Postnatal (early) testosterone surge - Within a day or 2 huge LH↑ followed by huge T↑ peaks ~2-4 months, gone ~6-7 months ● General stimulation, Penile growth and programming, (all due to T) LH↑ → T↑ ● Brain stimulation? Brain-growth stimulation? Programming? GI effects? GR effects?

The Ontogeny of Psychosexual Development:

Prenatal and Postnatal Influences on Gender Role, Gender Identity, ( and SO = Sexual Orientation)

Male Hypoactive Sexual Desire

Prevalence: - Age-related decline: a. 6% of younger men(18-24 yrs) report sexual desire problems b. 41% of older men aged 66-74 c. Men 16-44: Only 1.8% have persistent lack of interest - Culture: a. Low desire in 13% of European men b. Low desire in 28% of Southeast Asian men c. Guilt may be a factor - Risk factors: a. Mood & anxiety symptoms: performance, loss of control, pleasure, injury, assault history b. Self-esteem & relationship issues c. Alcohol use may ↓desire d. Physiological: Endocrine disorders: ↑prolactin, ↓testosterone

Are things looking up

Prevention Advocacy Education Screening Intervention Medical Behavioral Treatment Prompt diagnosis leads to better prognosis.

Healthcare Team: System of care for individuals with FASDs

Primary care provider manage routine issues (medical therapies) & educate/refer mother to prevent recurrence Dysmorphologist/Geneticist aid in diagnosis, differential diagnosis Developmental pediatrician evaluate developmental needs of the individual Mental/Behavioral health providers Psychologist, social worker, therapist Family Advocate

Interprofessional Team

Primary care providers (Family Med, OB/GYN, including PA, Nurse) Dysmorphologist Developmental pediatrician Psychologist Social Worker Therapists (PT, OT, SLP) maximize potential through early and persistent intervention use of adaptive techniques to overcome disability Nutritionists

ASK- Adolescent Substance Abuse Knowledge Base

Primary factors that affect increased or decreased drug use: Perceived risk Perceived social approval Perceived availability Parental attitude

Types of Psychosocial Treatment

Psychodynamic CBT Motivational Enhancement 12-step facilitation Contingency Management Network/family/group therapy Relapse Prevention

Why Teach About Sexuality?

Questions commonly asked of physicians Learn to practice professionally without becoming embarrassed, disgusted or stimulated Respect diversity in patients Do not impose your beliefs or biases and respect rights of those who are different => Exceptions: self-harm or harming others You do have a right to your beliefs as others do

Severity

Severity of effects depends on alcohol: Dosage Pattern of exposure Timing of exposure Duration of exposure

HIV Testing Recommendations for Adults and Adolescents

Routine HIV screening is recommended for all patients aged 13-64 years, in all health-care settings at least once

Stage Three Despair

Self Injury Burglary Armed Robbery Blackmail (usually with sex)

Behavior Problems

School-Age Attention-Deficit-Hyperactivity Disorder Learning Problems Poor Auditory Processing Memory Difficulties

Recommendations for Provider

Screen for sexual problems in a private environment and allow adequate time. Be sensitive to patient preferences regarding gender of the provider. Educate patients on lifestyle choices. Be aware of own prejudices and subconscious feelings; do not make assumptions

Stage Two: More Despair

Seeing Multiple Physicians Rx lifting/altering Late calls/cross coverage Fraudulent call-ins to pharmacies

Relapse Prevention

Seeks to identify precipitants that can lead to relapse Develop strategies to address these potential precipitants Generally time-limited/phase oriented

Step 11:

Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

Exhibitionistic Disorder

Sexual arousal from exposure of one's genitals to nonconsenting person Occurs > 6 months and causes distress or impairment Not children exposing genitals (normal behavior) Not between 2 consenting adults Prevalence: 2-4% of males, lower in females Examples College campuses: Long tradition of flashing & mooning at times U.C. Berkeley: exhibitionist attended class nude for several weeks before asked to leave Nudity legal in San Francisco until Dec. 2012 Reading: "When All the Laughter Died in Tears" by former Dallas Cowboy Lance Renshaw--exhibitionist's view

How HIV is transmitted

Sexual transmission accounts for ~88% of HIV transmission in the US Unprotected anal receptive intercourse associated with greatest transmission risk Female-to-male transmission is less efficient than male-to-female Oral-genital transmission risk is low, but it happens Injecting drugs with contaminated needles and/or equipment Infected mother to infant

Methadone For Chronic Pain

Significant accumulation with repeat dosing Initial t1/2 = 13-47 hrs => t1/2 = 48-72 hrs Strong m agonist & moderate NMDA antagonist Weak 5-HT & NE reuptake blocker QTc prolongation - esp if dose >100mg 50% urine elimination (caution in renal failure) Need appropriate induction phase to avoid iatrogrenic overdose.

Oklahoma Experience

Since 1985, nearing 1100-- 5 year graduates (PHP's began in late 1970's) Most never appeared before the board Small percentage of failures similar to national data Attempt to identify every physician at risk to protect the public 5 year success rate about 90%

Babies of Opiate - Addicted mothers

Small for gestational age Often experiencing withdrawal symptoms beginning shortly after birth Irritable Difficult to parent

Stimulants

Specific obstetric complications: Early pregnancy loss Abruptio placentae Premature onset of labor Chronic fetal hypoxia Intrauterine growth retardation Increased incidence of stillbirths

Classic Scams

Spilled the bottle The dog ate it Lost the prescription Washed in laundry Medication stolen Left it somewhere Lost my luggage No generics Multiple medication sensitivities Allergic to Kappa agonists The cough calls for . . . It's the only thing that works

Methadone Dosing

Start low, go slow First day: max 1st dose = 30mg max 1st 24 hrs = 40mg Maximum increase: 5-10mg every 1-2 days with close supervision. See the patient in your office FREQUENTLY. Target dose = dose that achieves adequate analgesia without intoxication or sedation

But the Healthcare Provider does not want to talk about it either!

Stereotype of an asexual older adult Stereotype of the monogamous and heterosexual relationship Do not want to offend the older adult Personal beliefs

Michele had lost 40 pounds in the last 4 months. She had relapsed on cocaine after being clean for one year. A series of events seem to have precipitated the relapse. She had lost custody of her newborn baby as well as 5 year-old-daughter who adored her. She was now with a boyfriend who also used and that had got her started again.

Substance abuse impacts women more adversely and this phenomenon is called the telescoping effect of substance abuse in women

Physician Problems

Substance-Related Disorders Mental Illness (Stress, Depression, Anxiety, etc.) Process Addictions Boundary/Relationship Disorders Personality Disorders - disruptive behaviors Age related problems - dementia Physical disabilities

Tx of Addictions at End of Life

Take a substance use history Involve a multidisciplinary team Set realistic goals for therapy Evaluate and treat comorbid psychiatry disorders Prevent or minimize withdrawal symptoms Consider impact of tolerance Apply appropriate pharmacologic principles to treat chronic pain Recognize specific drug abuse behaviors Utilize nondrug approaches as appropriate

Sexual Differentiation

Testis → 2 hormones = MIS and T — MIS → defeminizes embryo = F ductal atrophy — T as hormone → Brain, lean muscle mass — But T is also 2 Prohormones T as prohormone: 1) T→ (5α-reductase) DHT → prostate, penis, scrotum 2) T→ (aromatase) E + T→ sex drive, bone mass

Brain Regions Affected

The Cerebral Cortex The Hippocampus and Cerebellum The Corpus Callosum

Sexual Differentiation is a Male Process

The Male differentiates - in form and function => How? Why? — Y Chr has Sry, a gene acting almost like a switch — Sry "switches" off wnt4 and RSPO1 on Chr 1 → Gonadoblastema → testis

ABUSE

The habitual use of a legal or illegal substance to alter or affect one's mood, emotions, or state of consciousness for nonmedical reasons.

Evaluating the child in terms of GI:

The parents come to us, as clinicians, with ? GI (sex-of-raising) - We need to understand: - The Phenotype, Sex Chromosomes, Chr 1, ..., Gonads - Prenatal exposures (T, T+DHT, T but no DHT, ...)

Cocaine-exposed babies - "Crack Baby"

There are discrepancies in the research literature that identify and describe cocaine-exposed babies. This is partly a result of confounding factors of poverty, lack of prenatal care, family instability, and polydrug abuse. Most studies have not controlled for specific drug-use patterns or psychosocial variables. Epidemic in 1980s now decreased.

Patients do not bring it up!

They may be waiting for you to mention it They may think it is normal and not worth your time They are concerned that you will think they are a "sex maniac" or abnormal for still being sexually active They may believe sex with aging is wrong. They may be influenced by religious and cultural stereotypes.

DISRUPTIVE BEHAVIORS

Threatening or Abusive Language or Profanity Degrading or Demeaning comments Inappropriate Comments about care given by someone else, Docs, Nurses, Facilities Angry Outbursts, Rudeness, Verbal Attacks Unwanted Physical Contact Can be directed at patients, family members, staff or personnel, other professionals

Chronic Pain Defined

Traditionally defined as lasting >3-6 months But practically can be difficult to define. Pragmatic definition: Lasts months to years, rather than the weeks to months of acute pain Chronic pain more likely to have comorbid addiction than acute pain.

Overview: Myths

Treating older adults for substance use disorders is not worthwhile. Alcohol or substance abuse problems cannot be successfully treated in older adults. Treatment for this population is a waste of health care resources.

Family Therapy

Useful when pt doesn't want help & to aid recovery once pt has sought help Substance abuser refuses tx: Al-Anon & coping skills therapy Substance abuse in active tx: network therapy, family systems therapy, behavioral couples therapy

What is Fetal Alcohol Spectrum Disorder (FASD)?

Umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. Includes physical, mental, behavioral, and/or learning disabilities, with possible lifelong implications Includes fetal alcohol syndrome (FAS), as well as less global effects of alcohol upon a fetus [alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD)] FASD is NOT a clinical diagnosis

Medical Interventions: Drug Testing

Useful for deterring & detecting recent drug use Does NOT identify addiction or dependence Helps with issue of denial. Can test any body fluid (urine, blood, saliva, hair, sweat Test via immunoassay (Ag-Ab reaction) Confirmation test: GC-MS Most common substances tested (cannabis, cocaine, PCP, amphet, opioids (morphine & codeine)

More examples of disruptive physician

Utilizes threatening or intimidating physician contact. Makes public derogatory comments about the quality of care being provided by other Physicians, nursing personnel, or the hospital. Writes inappropriate medical records entries concerning the quality of care being provided by the hospital or individual. Imposes idiosyncratic requirements on ancillary staff which have nothing to do with better patient care, but serve only to burden staff with "special" techniques and procedures

Step 1:

We admitted we were powerless over alcohol- that our lives had become unmanageable.

OHPP Duties

We help sick Docs get healthy Intervene on Addicted Doctors and get them into Treatment We try to get Docs back to work Our Docs can avoid the licensing board We stress Non-Punitive Actions and Compassionate Healing

The Ethics of Assessing the Child's GI:

We need to understand: - The clinical, social, ethical issues of nonconformity and making children normal - as the child's advocate AND as the parents' advocate - Why should we follow them over time? - How should we follow them over time?

Step 6:

We were entirely ready to have God remove all these defects of character.

Monitoring

Wellness Programs - PHP's - improve outcome Contract important Abstinence, Medications, Random urine monitoring, Groups, Therapy, Self-help groups, etc. Length of follow-up - lifetime preferable?

Biomedical MechanismsAssociated with FAS/FASD

What are some of the effects of alcohol during pregnancy (particularly on the nervous system)? Does alcohol get to the fetal brain and other organs? How can alcohol influence the developing brain?

Ethanol Distribution

Where does the 'one' drink go? Can alcohol cross the placenta and what tissues does it get to?

Sexual Preference (Sexual Orientation)

Whether the preference for a sexual partner is for opposite sex, same sex or both Complex, and many studies explore Some theories on sexual orientation, gender identity:

DSM 5: Substance Use Disorder

Within the past 12 months at least 2 of the following: 1) Taking the substance in larger amounts or for longer period than intended 2) Persistent desire or unsuccessful effort to cut down or control use 3) Lot of time spent in activities to obtain, use, or recover from the effects of the substance 4) Craving or strong desire to use 5) Recurrent use causing failure to fulfill major role obligations 6) Continued use despite persistent or recurrent social or interpersonal problems from substance 7) Important activities given up because of use 8) Recurrent use in physically hazardous situations 9) Continued use despite knowledge of having a persistent or recurrent physical or psychological problem from substance 10) Withdrawal Characteristic withdrawal symptoms for the substance Substance, or a closely related substance, is used to alleviate withdrawal symptoms 11) Tolerance A need for markedly increased amounts to achieve desired effects A markedly diminished effect from same amount of substance 2-3= mild ,4-5= moderate, 6+= severe

Adolescent Substance Use- Why are we covering this topic?

Younger start= greater risk Implications: brain development psychological and behavioral problems social development medical care and treatment family use risky behaviors

Appropriate Treatment Strategies for motivational counseling

a. Acknowledges readiness to change b."Meets people where they are" c. Enlist patients in their own recovery by motivating them to shift their perceptions about their drinking habits d. Proven effective with older adults