Uppers, Downers, and Everything In-Between: Medication Management of Drug Addiction

Transcription

1 Uppers, Downers, and Everything In-Between: Medication Management of Drug Addiction Dustin DeMoss, D.O., M.S. Medical Director, Consult/Liaison Psychiatry Medical Director Integrated Specialty Unit John Peter Smith Hospital, Fort Worth, TX Assistant Professor University of North Texas Health Science Center Disclosures This presentation discusses off-label use of medications. Objectives Review trends of substance use disorders. Identify signs/symptoms of substance use. List FDA approved medications for substance use disorders. 1

2 Pre-test Question 1 Which of the following medications are approved by the Federal Drug Administration (FDA) for relapse prevention in cocaine addicted patients? A B C D Lisdexamfetamine Baclofen Naltrexone None of the above Pre-test Question 2 Which of the following treatments is recommended for use in opiate addicted pregnant women? A B C D Opiate detoxification with subsequent abstinence Methadone maintenance Buprenorphine/naloxone (suboxone) maintenance None of the above 2

3 Pre-test Question 3 Which of the following club drugs has the highest lifetime prevalence in people 26 years or older? A B C D Phencyclidine (PCP) 3,4-Methylenedioxymethamphetamine (MDMA) Ketamine Lysergic acid diethylamide (LSD) Why? Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services 3

4 Uppers Cocaine Khat Synthetic Cathinones Synthetic Cannabinoids Stimulants Methamphetamines Uppers Cocaine Khat Synthetic Cathinones Synthetic Cannabinoids Stimulants Methamphetamines Signs/Symptoms Increased: Temperature Blood pressure Pulse anxiety Paranoia Withdrawal: Depression Fatigue Restlessness Cocaine 4

5 Cocaine Street names Blow Bump Snow Toot 5

6 Crack cocaine Street names 24-7 Apple jacks Badrock Ball Base Beat Candy Chemical Cloud Cookies Crack Crumbs Crunch & munch Devil drug Dice Electric kool-aid Fat bags 6

7 Cocaine treatment No FDA approved medications Cognitive behavioral therapy (CBT) 12-step Cocaine treatment No FDA approved medications Cognitive behavioral therapy (CBT) 12-step Mooney et al. Pilot study of the effects of lisdexamfetamine on cocaine use: A randomized, double-blind, placebo-controlled trial. Drug and alcohol dep. 8/2015; 153: Khat 7

8 Khat Catha edulis Contains 2 CNS stimulants: cathinone and cathine. Symptoms: euphoria, hyperactivity, anorexia, and lack of fatigue. Long term: tooth decay, gum disease, GI ulcers. Withdrawal: depression, nightmares, lack of energy. Khat Treatment No FDA approved medications Unclear addictive properties of Khat Synthetic cathinones Street names Flakka Bloom Cloud Nine Lunar Wave Vanilla Sky Scarface Intoxication Paranoia agitation Hallucinations violent behavior Nosebleeds diaphoresis Nausea vomiting Withdrawal Depression anxiety Insomnia paranoia 8

9 Synthetic cannabinoid Street names K2 Spice Black Mamba Bliss Bombay Blue Fake Weed Fire Genie Moon Rocks Smacked Intoxication Tachycardia, nausea, vomiting Confusion, psychosis, agitation Poor cardiac perfusion Withdrawal Headaches, irritability Depression, anxiety Stimulant use Amphetamines Methamphetamines Differences 9

10 Differences J. Shawn Goodwin et al. J. Biol. Chem. 2009;284: by American Society for Biochemistry and Molecular Biology 10

11 Amphetamines Generic/Brand name Amphetamine/Adzenys Dextroamphetamine/Dexidrine Dexmethylphenidate/Focalin Levoamphetamine/Adderall Lisdexamfetamine/Vyvanse Methylphenidate/Ritalin Street name Bennie or Bennies Amped or Ampes Benz or Benzies Cartwheels Blue Mollies or Black Mollies Speed Jelly Beans or Super Jellies Sparkles Dexies or Dexy Footballs 11

12 Methamphetamines 12

13 Treatment Amphetamine No FDA approved medications 12 step model CBT Methamphetamine No FDA approved medications 12 step model CBT Treatment Amphetamine No FDA approved medications 12 step model CBT Methamphetamine No FDA approved medications 12 step model CBT Three DBPCT showed clinical effect in some populations with bupropion, modafinil, and naltrexone. Downers Alcohol Opiates (including pain relievers) Kratom Sedatives Tranquilizers Signs/Symptoms Increased: euphoria, respiratory depression, flushed skin, bradycardia, altered wakeful/drowsy Withdrawal: restless, anxious, nausea, vomiting, diarrhea, cramps, tremor, hallucinations, seizure, death 13

14 Alcohol 14

15 9/29/2016 Alcohol treatment Pharmacologic Acamprosate Psychosocial Interventions CBT Disulfiram Motivational enhancement Naltrexone (oral or extended-release) Topiramate 12-Step facilitation Gabapentin Heroin Street names Dragon (smoking heroin is called Chasing the Dragon ) Dope H White Lady China White Mexican Mud Horse Scag Black Tar Brown Sugar Chiva Tar Snowball 15

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17 Kratom Mitragyna speciosa korth Opioid-like activity. Produces both stimulant and sedative effect. Sign/symptoms: Low dose: increased energy, alertness. High dose: sedation, euphoria, decreased pain Withdrawal: insomnia, irritability, flu-like symptoms Nonmedical prescription drug use 17

18 Nonmedical prescription pain-reliever use 18

19 19

20 Oxycontin use 20

21 cdc.gov Fentanyl Trade names: Actiq, Fentora, Duragesic 100x more potent than morphine ~16,000 ED visits >20,000 DEA fentanyl seizures ~900 in 2014 up to >3000 in 2015 Carfentanil Janssen Pharmaceutica The most potent opioid used commercially Typically only used in animals It has a quantitative potency approximately 10,000 times that of morphine 100 times more potent that fentanyl 21

22 Opiate treatment Agonist therapy Methadone Buprenorphine Buprenorphine/naloxone (suboxone) Pregnant patients with opioid dependence should be encouraged to commence opioid agonist pharmacotherapy. Antagonist therapy Naltrexone World Health Organization (WHO). Guidelines for the identification and management of substance use and substance use disorders in pregnancy. Geneva (Switzerland): World Health Organization (WHO); Sedative use Barbiturates Methaqualone Phenobarbital 22

23 Tranquilizer use Benzodiazepines 23

24 Tranquilizer treatment Withdrawal management Slow benzodiazepine taper Slow phenobarbital taper Adjunct treatment with AED Slow flumazenil infusion Maintenance No FDA approved medications Limited evidence for psychosocial intervention BZD maintenance treatment not preferred over abstinence Everything In-between Phencyclidine (PCP) Lysergic acid diethylamide (LSD) 3,4-Methylenedioxymethamphetamine (MDMA) 24

25 PCP Street name Angel Dust Boat Love Boat Peace Pill Intoxication Vertical nystagmus Psychosis agitation Flushing diaphoresis Withdrawal Headaches irritability Depression suicidal thoughts 25

26 LSD Street names Acid Blotter Blue Heaven Cubes Microdot Yellow Sunshine Intoxication Reality distortion Psychosis paranoia Mood lability hypertension Tachycardia tremor Withdrawal Unknown 10.9% lifetime prevalence in those ages 26 and older. Making it the most commonly used club drug in the U.S. 26

27 MDMA Street names Adam Clarity Eve Lover's Speed Peace ecstasy Intoxication Enhanced sensory perception Confusion lowered inhibition Hypertension tachycardia Withdrawal Fatigue depression Insomnia 27

28 Treatment Phencyclidine (PCP) Lysergic acid diethylamide (LSD) 3,4- Methylenedioxymethamphetami ne (MDMA) No FDA approved medications Post-test Question 1 Which of the following medications are approved by the Federal Drug Administration (FDA) for relapse prevention in cocaine addicted patients? A Lisdexamfetamine B Baclofen C Naltrexone D None of the above 28

29 Post-test Question 1 Which of the following medications are approved by the Federal Drug Administration (FDA) for relapse prevention in cocaine addicted patients? A Lisdexamfetamine B Baclofen C Naltrexone D None of the above Post-test Question 2 Which of the following treatments is recommended for use in opiate addicted pregnant women? A Opiate detoxification with subsequent abstinence B Methadone maintenance C Buprenorphine/naloxone (suboxone) maintenance D None of the above Post-test Question 2 Which of the following treatments is recommended for use in opiate addicted pregnant women? A Opiate detoxification with subsequent abstinence B C D Methadone maintenance Buprenorphine/naloxone (suboxone) maintenance None of the above 29

30 Post-test Question 3 Which of the following club drugs has the highest lifetime prevalence in people 26 years or older? A Phencyclidine (PCP) B 3,4-Methylenedioxymethamphetamine (MDMA) C Ketamine D Lysergic acid diethylamide (LSD) Post-test Question 3 Which of the following club drugs has the highest lifetime prevalence in people 26 years or older? A Phencyclidine (PCP) B 3,4-Methylenedioxymethamphetamine (MDMA) C Ketamine D Lysergic acid diethylamide (LSD) References Drug Enforcement Agency 11/2013 Elkashef et al. Bupropion for the Treatment of Methamphetamine Dependence. Neuropsychopharmacology (2008) 33, Fentanyl. Goodwin et al. Amphetamine and Methamphetamine Differentially Affect Dopamine Transporters in Vitroand in Vivo. J. Biol. Chem. 2009;284: Karila et al. Pharmacological approaches to methamphetamine dependence: a focused review. British Journal of Clinical Pharmacology. 2010; 69: Khat. 8/2013 Kratom. 1/2013 Liebrenz et al. Attitudes towards a maintenance (-agonist) treatment approach in high-dose benzodiazepine-dependent patients: a qualitative study. Harm Reduction Journal. 1/2016 Management of Substance Use Disorders Work Group. VA/DoD clinical practice guideline for the management of substance use disorders. Version 3.0. Washington (DC): Department of Veterans Affairs, Department of Defense; 2015 Dec. Mooney et al. Pilot study of the effects of lisdexamfetamine on cocaine use: A randomized, double-blind, placebo-controlled trial. Drug and alcohol dep. 8/2015; 153: National Institute on Drug Abuse. Commonly Abused Drugs. National Drug Early Warning System. World Health Organization (WHO). Guidelines for the identification and management of substance use and substance use disorders in pregnancy. Geneva (Switzerland): World Health Organization (WHO); Young et al. Nipping Cue Reactivity in the Bud: Baclofen Prevents Limbic Activation Elicited by Subliminal Drug Cues. JournalofNeuroscience, April, (14):

31 Questions? 31