10/11/2017. Identifying and Addressing Addiction vs Dependence in Medical Practices

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1 Identifying and Addressing Addiction vs Dependence in Medical Practices Joseph N. Ranieri, DO, FAAFP, Diplomate-American Board Of Addiction Medicine Medical Director The Presenter, Dr. Joseph N. Ranieri, has declared no conflicts of interest for speaking engagements with any Pharmaceutical entity. Physician is an employee of Seabrook House. Bridgeton, NJ Westfield, PA Cherry Hill, NJ Northfield, NJ Morristown,NJ 1 2 Abuse-Misuse - use in a manner other than what the prescribing physician / medical provider intended. Dependence - a physiologic process, which is a predictable event in the prescription of opioids, benzodiazepines, barbiturates and stimulants. Dependence is dose-, time- and potency-related and may result in tolerance (to side effects and to therapeutic effects) and withdrawal. Physiologic dependence is not necessarily addiction. Understanding the differences among these terms helps physicians/ medical providers understand the liability risks and helps patients overcome the stigma of getting hooked on a legitimately used controlled substance. Addiction is a primary, chronic disease of brain reward, motivation, 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 by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control craving, diminished recognition of significant problems with one s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. WITHOUT TREATMENT or engagement in recovery activities, addiction is progressive and can result in disability or premature death. THE ASAM CRITERIA, Treatment Criteria For Addictive, Substance-Related and Co-Occurring Conditions, American Society Of Addiction Medicine, Third Edition, Sustained recovery and an improved quality of life should be the expected goal of treatment for substance use disorders. 1. A broadly representative group of experts convened by the Betty Ford Institute in 2007 defined recovery as a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship. 2. The American Society of Addiction Medicine (ASAM) defined recovery as a process of sustained action that addresses the biological, psychological, social, and spiritual disturbances inherent in addiction. This effort is in the direction of a consistent pursuit of abstinence, addressing impairment in behavioral control, dealing with cravings, recognizing problems in one s behaviors and interpersonal relationships, and dealing more effectively with emotional responses. Recovery actions lead to reversal of negative, self-defeating internal processes and behaviors, allowing healing of relationships with self and others. The concepts of humility, acceptance, and surrender are useful in this process.. Abstinence defined intentional and consistent restraint from the pathological pursuit of reward and/or relief that involves the use of substances and other behaviors. 3. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery from mental disorders and substance use disorders as, a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. 4. WORLD SERVICE BOARD OF TRUSTEES BULLETIN #29 -Regarding Methadone / Suboxone. One of the first things we heard was that NA is a program of complete abstinence. That is CORRECT. However, the only requirement for membership is a desire to stop using. The Treatment of Medical problems and Mental Illness with Psychoactive medications that have abuse potential may result in surfacing the already predisposed Disease Of Addiction in patients with genetic predisposition & as well as those exposed to a history of environmental stressors ( i.e physical, emotional, sexual, and psychological trauma ). Creating a New Standard for Addiction Treatment Outcomes A Report from the Institute for Behavior and Health, Inc.(1-3) 5 6 1

2 History of present illness: Patient is a 30-year-old female presents to the office with a history of interstitial cystitis diagnosed approximately 15 years ago with periods of exacerbation and remission. Other medical problems include Gastroparesis, Anxiety / Panic, MDD-Depression, PTSD-relationship verbal abuse, Nephrolithiasis Medications include: Oxycodone (Daily range mg), Hydromorphone 8-12mg / day, Buprenorphine-Suboxone-( 12-16mg/ day ) ( i.e. and other opiate medications B & O suppositories ) at various interval times. Other medications include: Diazepam intravaginal suppositories, Klonopin 0.5 mg twice a day, Soma 350 mg 4 times a day as needed, Seroquel 50 mg at bedtime, Remeron 30 mg at bedtime, Zoloft 50mg daily, B & O Suppositories Substance Abuse History / Alcohol use history-unremarkable DAST-21 Questionnaire + one question for experimenting with drugs yrs ago. Mother is present during the history and physical as an advocate Review of symptoms; other 10 point review of symptoms were negative except for Patient Comfort Assessment Form, Anxiety Rating Scale Zung, PHQ-9 Depression Questionnaire. Allergies: Compazine, Reglan, Phenergan, nonsteroidal anti-inflammatory medications ( upset stomach dyspepsia ). 7 Social history; divorced with associated verbal /emotional abuse. Occupation, teacher. Patient ; + nicotine ½ ppd x 16 yr. started age 14 Family history father with kidney cancer Urine drug screen positive for buprenorphine, benzodiazepines. Vital signs include pulse 114, temperature 98.1, blood pressure 99/81. Physical exam unremarkable. Assessment and plan: 1. Chronic pain syndrome secondary to interstitial cystitis-prescribe buprenorphine off FDA- label for pain management 8 mg twice a day 2. Gastroparesis-proton pump inhibitor-prilosec, recent Gastric Device Placed. 3. Anxiety/depression, history of trauma, emotional-verbal, medications include Remeron, clonazepam, diazepam, Seroquel, d/c -Soma, Oxycodone,-140mg/ day d/c Marinol ( patient claims filled but not taken ) 4. Chronic Nephrolithiasis-asymptomatic 5. Recommend support management via support group, interstitial cystitis, recommend meetings for recovery awareness at our office. 6. Coordination of care-with other providers psychiatrist, Uro-Gyn, holistic provider to limit / eliminate Psychoactive Medications, Sedatives, Muscle relaxers, Opiates 7. Review NJ RX Reporting System monitoring,!2 step recovery, CBT 8. Coordinated Care amongst specialist to minimize duplication of medications. 9. Transdermal Pain Cream-Tertracaine, Lidocaine, Baclofen, Clonidine, Neurotin, ibuprofen, Elavil 8 Patient has 3 different Uro-Gynecologists- 1. Dr A. Rx B & O Suppositories & Lyrica 2. Dr B. Rx Vaginal Diazepam & Oral Diazepam, Various Opiates. 3. Dr C. Rx. Multiple Opinions Patient Has 1 primary care provider & Multiple Urgent Care Centers ( Rx Antibiotics ) Patient Has Holistic Medicine Provider Rx. Soma Patient Has 2 Ob-Gyn Providers Patient Has Psychiatrist Rx Clonazepam, Remeron, Seroquel, Zoloft. Patient Has a Therapist which she underutilizes. Patient now Has an Addiction Specialist Rx Suboxone for Pain Management of Substance Use Disorder ( Patient in denial ) Goal is to eliminate duplications of medications in the same pharmacologic class and engage patient in the Bio-Psychosocial aspect of the Disease Treatment of Dependence Pain & Addiction. Fill Date Product, STR, Form Quantity Days 30 10/17/2014 Diazepam Suppository 2MG 1 daily 60 Patient use 1or 2 per day 10/23/2014 Suboxone 2MG, 8 MG, Film, Soluble I twice a day /02/2014 Clonazepam, 0. 5 MG, Tablet Patient use 2 per day 10/02/2014 B & O Suppository Patient use for exacerbation most 10 per month Pt ID 9 10 Fill Date Product, STR, Form Quantity Days Fill Date Product, STR, Form Quantity Days 09/24/2014 Suboxone, 2MG, 8 MG, Film, Soluble -1 twice a day /2/2014 Oxycodone 10mg/325 Patinet used 1 q6hr prn x 2 days /18/2014 Diazepam Suppository 2MG -1 daily Patient use 1 or 2 per day B & O Suppository 9/10/ Patient uses 10 per month Oxycodone 10mg /325 9/6/ Patient use one q6hr x 3 days, holding suboxone Clonazepam, 0.5 MG Tablet- 09/05/ Patient use 2 per day Lyrica 150mg 9/4/ Patient uses as needed 1-2 per day exacerbations Dronzabinol, 2.5 MG, Capsule 1 daily 09/01/ Prescription filled but not used for Gastroparesis Diazepam, 2MG, suppository 8/20/ Patient use 1-2 per day 8/24/2014 Suboxone 8mg Film 1 twice a day /12/2014 Clonazepam, 0.5mg, tablet Patient uses 2 per day 8/12/2015 B & O Suppository Patient use 10 per month 7/19/2014 Soma 350mg Patient uses as needed 07/29/2014 Suboxone, 2MG, 8MG, Film, Soluble /2/2014 Diazepam, 2MG, TaBlet Patient uses in addition to vaginal supposoitory Clonazepam, 0.5MG, Tablet 07/01/ Patient use 2 per day 06/28/2014 Suboxone, 2 MG; 8 Mg, Film, Soluble /05/2014 Carisoprodol, 350 MG, Tablet /05/2014 Oxycotin 40mg 5 5 Patient used for 5 days, holding suboxone 06/04/2014 Clonazepam, 0.5 MG, Tablet Patient uses 2 per day 05/24/2014 Diazepam, 2MG, Tablet Patient use as needed in addition to Vaginal suppository 05/21/2014 Suboxone, 2MG; 8MG, Film, Soluble Patient using one daily 05/09/2014 Clonazepam, 0.5 MG, Tablet Patient uses 2 per day 05/05/2014 Oxycotin 40mg Patient uses one twice a day 05/01/2014 Alprazolam,.25 MG, tablet /22/2014 Suboxone, 2MG; 8 MG, Film, Patient uses as needed 07/18/2014 Clonazepam, 0.5mg, tablet Patient uses 1-2 per day /13/2014 Oxycodone 5, 325mg acetaminiphen

3 Fill Date Product, STR, Form Quantity Days Fill Date Product, STR, Form Quantity Days 04/08/2014 Alprazolam, 0.5 MG, Tablet /08/2014 Oxycodone Hydrochloride, 15 MG, Tablet /08/2014 Oxycotin, 40 MG, Tablet, Film Coated, Extended Release /04/2014 Oxycodone Hydrochloride, 30 MG, Tablet /04/2014 Lorazepam, 0.5 MG, Tablet /30/2014 Hydromorphone Hydrochloride, 2MG, Tablet /15/2014 Lorazepam, 0.5 MG Tablet /11/2014 Suboxone, 2MG, 8 MG, Film, Soluble /08/2014 Carisoprodol, 350 MG, Tablet /10/2014 Carisoprodol, 250 MG, Tablet /10/2014 Suboxone, 2Mg, 8 Mg, Film, Soluble /27/2014 Suboxone, 2Mg, 8 Mg, Film, Soluble /30/2013 Suboxone, 2MG;8MG, Film, Soluble /24/2013 Clonazepam, 1MG, tablet /16/2013 Suboxone, 2MG;8MG, Film, Soluble /13/2013 Oxycodone and acetaminophen, 325 Mg; 5MG, Tablet /09/2013 Suboxone, 2MG;8MG, Film, Soluble /01/2013 Suboxone, 2MG;8MG, Film, Soluble /30/2013 Suboxone, 2MG;8MG, Film, Soluble /25/2013 Suboxone, 2MG;8MG, Film, Soluble /23/2013 Clonazepam, 1 MG, Tablet /14/2013 Suboxone, 2MG;8MG, Film, Soluble /01/2013 Oxycodone Hydrochloride, 30 MG, Tablet /31/2013 Carisoprodol, 350 MG, Tablet /08/2014 Clonazepam, 1 MG, Tablet /30/2013 Oxycodone and Acetaminophen, 325 Mg, 5 Mg, Tablet DSM-5 does not separate the diagnosis of substance abuse and dependence as in DSM-IV, rather, criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders. DSM-5 substance use disorder criteria are nearly identical to DSM-IV substance abuse and dependence criteria combined into a single list with two exceptions. The DSM-IV recurrent legal problems, has been deleted, and a new criterion, craving or strong desire to use a substance, has been added. In addition, the threshold for substance use disorder in DSM-5 is a set of 2 or more criteria, in contrast DSM-IV, 1 or more criteria for substance abuse, 3 or more criteria for dependence Severity criteria: 2-3 mild, 4-5 moderate, 6 or more severe A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12 month period: 1. Impaired Control: Opioids are often taken In larger amounts over a longer period then was intended.* 2. Impaired Control: There is a persistent desire or unsuccessful efforts to cut down or control opioid use.* 3. Impaired Control: A great deal of the time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.* 4. Impaired Control: Craving, or strong desire or urge to use opioids.*** 5. Social Impairment: Recurrent opioid use resulting in a failure to fulfill major role operations at work, school, or home.** 6. Social Impairment: Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.** 7. Social Impairment: Important social, occupational, or recreational activities are given up or reduced because of opioid use.* 8. Risky Use: Recurrent opioid use in situations in which it is physically hazardous.** 9. Risky Use: Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.** 10. Tolerance, as defined by either for the following: * a) A need for markedly increased amounts of opioids, to achieve intoxication or desired effect. b) A markedly diminished effect with continued use of the same amount of an opioid. Note: This criterion is not considered to be met for those taking opioids, solely under appropriate medical supervision 11. Withdrawal, as manifested by either of the following: * a) The Characteristic opioid withdrawal syndrome. b) Opioids are taken to relieve or avoid withdrawal symptoms. Note: This criterion is not considered to be met for those individuals take opioids solely under appropriate medical supervision. Severity criteria: 2-3 mild, 4-5 moderate, 6 or more severe * DSM-IV Dependence **DSM-IV Abuse ***DSM-5 addition ( Formerly DSM-IV 17 Abuse-recurrent substance related legal problems) Standard Drug Addiction criteria has and continues to be unsatisfactory when attempting to characterize iatrogenic addiction. For Pain patients, some drug seeking behaviors are different from behaviors that are listed by standard criteria and are focused on obtaining Opiates from prescribers (aberrant behaviors- i.e. doctor shopping, frequent lost prescriptions, repeated request for early refills). Pain patients who are treated continuously with opioids may not manifest any aberrant behaviors because they are effectively receiving maintenance therapy. When Opiates suddenly are not available, addiction behaviors will emerge. Washington State Law regarding Opioid Ceiling Dose-the rule sets a ceiling ( in terms of daily morphine equivalent dose ) on the amount of opioid that can be prescribed for chronic (non acute or cancer ) pain without consultation with a pain specialist unless the individual is functioning well on a stable or tapering dose. This trend is emerging also, by manage care and insurance companies. This may cause emerging addiction behaviors on patients on existing opiates who do not have the opportunity or are unwilling to remain on same dose or taper in a timely manner. 18 3

4 NJ RX Prescription Monitoring System- Use It! It s not hard work to establish one More critical to share data between state when close to boarders Multiple controlled Rx s per month More than one class of controlled Rx More than one prescriber More than one drug store or town Self prescribing is never, never OK. Long distance between prescriber and patient Suboxone-Buprenorphine Rx with other Controlled drugs Like Benzodiazepines/ Amphetamines / Opiates / Muscle relaxers To score them by risk: 1 year review 1 point for each class of controlled Rx-4 1 point for each prescriber -3 1 point for overlapping same class -2 2 points for each pharmacy -2 2 Points if different prescriber towns some risk 8-10 higher risk Over 10 is a problem TL 11-Case Presentation

5 Patients can present with red flags for alcohol and drug problems. Red Flag Complaints for Substance-Abuse Problems Frequent absences from school or work History of frequent trauma or accidental injuries Chronic Non-Cancer Pain Mental Illness / Depression or anxiety Labile hypertension Gastrointestinal symptoms, such as epigastric distress, diarrhea, or weight changes Sexual dysfunction Sleep disorders Multiple Providers ( NJ RX Reporting System ) Results from the Epidemiologic Catchment Area study demonstrated that 47 percent of patients with a lifetime diagnosis of schizophrenia or Schizophreniform disorder met criteria for some form of substance abuse. URINE DRUG SCREEN THESE PATIENTS! Substance Abuse was found in: 83.6 % of patients with antisocial personality disorder 23.7% of patients with anxiety disorders 32% of patients with affective disorders Suspicion of substance abuse is important not only because of the prevalence of this disorder, but also because it is very difficult to treat Mental Illness if concomitant substance abuse is unrecognized.* *Urine drug Screening & Treatment Contracts in the Treatment of Mental Disorders & Chronic Pain / Dependence/Addiction/ Prescribing All Medications with Abuse Potential-Opiates & Tramadol-Nucynta Nucynta, Benzodiazepines, Fioricet,, Stimulants, Diet Pills, Medications for ADD/ADHD, some Muscle relaxers, Insomnia Medications, & Other Psychoactive Drugs With Sedative Properties. Nearly 40% of all pt s had no opiates on UDS 11% tested positive for illicit drugs Unprescribed opiates in 29% of samples Dr. Leider startling results Jefferson School of Population Health and Ameritox The Current Opioid Misuse Measure (COMM) is a brief patient self-assessment to monitor chronic pain patients on opioid therapy. The COMM was developed with guidance from a group of pain and addiction experts and input from pain management clinicians in the field. Experts and providers identified six key issues to determine if patients already on long-term opioid treatment are exhibiting aberrant medication-related behaviors: Signs & Symptoms of Intoxication Emotional Volatility Evidence of Poor Response to Medications Addiction Healthcare Use Patterns Problematic Medication Behavior

6 Deaths from drug overdose have been steadily rising over the past two decades and have become the leading cause of injury death in the United States. Every day in the United States, 120 people die as a result of drug overdose & another 6,748 are treated in the ER for misuse or abuse. Nearly 9 out of 10 poisoning deaths are caused by drugs. Drug Overdose was the leading cause of injury death in Among people 25 to 64 years of age,drug overdose caused more deaths than motor vehicle traffic accidents. In 2013 drug overdose deaths, approximately 51% were related to pharmaceuticals drugs. Risk of Fatal overdose maybe directly related to amount of Opiate prescribed on a daily basis Doses ( Morphine Equivalent ) mg/day had a 3.7- fold increase in overdose risk. Doses ( Morphine Equivalent ) > 100mg/day ( 66.7mg/ day oxycodone ) had a 8.9-fold increase in overdose risk with 1.8% annual overdose rate. Clinical features Patients Patients Who are with pain Addicted to opioids Compulsive drug use Maybe* Common Craving drug (when not in pain) Maybe* Common Obtain or purchase drugs Rare Common from nonmedical sources. Procure drugs through illegal activity Absent Common Escalate opioid dose without medical Maybe** Common instructions Supplement with other opioid drugs Unusual Common Demand specific opioid agents Maybe* Frequent Can stop use when effective alternative Usually Usually Not treatments are available Prefers specific routes of administration No Yes Can regulate use according to supply Sometimes* No */ ** presenters opinion ** subjective presentation of symptoms with or without manipulation ( change tolerance set point/hyperalgesia )

7 Painful bladder syndrome/interstitial cystitis (PBS/IC) is a condition diagnosed on a clinical basis and requiring a high index of suspicion by the clinician. Simply put, it should be considered in the differential diagnosis of the patient who presents with chronic pelvic pain that is often exacerbated by bladder filling and associated with urinary frequency. The term Interstitial cystitis, was not at all descriptive of the clinical syndrome or the pathologic findings in many cases leading to the current effort to reconsider the name of the disorder and even the way it is positioned in the medical spectrum Tricyclic Antidepressants (Amitriptyline) have three major pharmacologic actions: (1) central and peripheral anticholinergic actions (2) block the active transport system in the presynaptic nerve ending responsible for reuptake of serotonin and noradrenaline (3) they are sedatives Antihistamines- Used since late 1950s, postulated that the local release of histamine may be responsible for, or accompany the development of, IC. Sodium Pentosan Polysulfate- A heparin analog, thought to decrease the epithelial permeability barrier (GAG layer) - 3% to 6% of which is excreted into the urine from oral pill Systemic corticosteroids Hormones Vitamin E Anticholinergics Antispasmodics Calcium channel antagonist (nifedipine) Cysteinyl leukotriene D4 receptor antagonist (montelukast) Oral L-arginine, an over-the-counter amino acid preparation, was purported to increase nitric oxide-related enzymes Dietary Restrictions The long-term, appropriate use of pain medications forms an integral part of the treatment of a chronic pain condition such as IC as Last Resort With the results of major surgery anything but certain, the use of longterm opioid therapy in the rare patient who has failed all forms of conservative therapy over many years may also be considered NSAID s and Acetaminophen Smoking Cessation Massage and Acupuncture Meditation and Mindfulness - (Jon Kabat-Zinn UMassMedSchool) Exercise and Sunshine PT and OT Improve Clinical recognition of Chronic Pain Increased use of non-opiate treatment modalities Better risk stratification of patients when opiates are used

8 Oxycodone Rx s increased 50% to 29 million Fentanyl Rx s increased 150% to 4.6 million Morphine Rx s increased 60% to 3.8 million

9 apparent opioid tolerance is not synonymous with pharmacological tolerance, but may be the first sign of opioid-induced pain sensitivity suggesting a need for opioid dose reduction. repeated opioid administration could lead to a progressive and lasting reduction of baseline nociceptive thresholds, hence an increase in pain sensitivity. Mao et al, Pain, 100 (2002) It occurs more frequently in the young It is probably on the same receptor that produces euphoria It occurs with the first dose of an opioid and is exacerbated by each subsequent dose If the pain condition is stable and the pain is worse, the opioids are not the solution, they are the problem Despite absence of direct organ-specific toxicity, opioids nonetheless produce many adverse effects Hyperalgesia -Mao, Pain, 2002 Respiratory depression Safety Studies associated with chronic use of opioids has simply not been studied - Farney, et.al., Chest, 2003 No long term studies for efficacy or safety- Furlan et al.,14 in a recent review of RCT of opioids for CNCP, concluded that the overall effectiveness of opioids for Pain was modest, and that the effect on function was small. Most of the RCT were shorter than 4 weeks, and none was longer than a few months Anxiety disorders Antidepressants (most) Buspirone (Buspar) Anticonvulsants (valproic acid [Depakene], gabapentin [Neurontin]) Selected antihypertensives (beta blockers) Atypical neuroleptics (olanzapine [Zyprexa], quetiapine [Seroquel], risperidone [Risperdal])-No Indication for anxiety / Consider Avoiding / Recommend Psychiatric Consult. ( Can cause Metabolic Syndrome ) Insomnia Sedating antidepressants Trazodone (Desyrel) Doxepin (Sinequan) Amitriptyline (Elavil) Mirtazepine (Remeron) Antihistamines Avoid Any Benzodiazepine including Atypical ( Ambien etc. ) Attention-deficit disorder Pemoline (Cylert) Bupropion (Wellbutrin) Desipramine (Norpramin) Venlafaxine (Effexor) Clonidine (Catapres) Selective serotonin reuptake inhibitors Pain Nonsteroidal anti-inflammatory drugs Topical Compounding Creams ( avoid Ketamine ) Acetaminophen Antidepressants Corticosteroids Muscle relaxants Opiates associated with fourfold higher hip Fx risk 70 % higher risk for hospitalizations Doubling of all-cause mortality compared with NSAID s A study by Franklin et al showed that opioids prescribed within 6 weeks of injury doubles the risk of disability one year later (Franklin, Stover, Turner, Fulton-Kehoe, & Wickizer, 2008). The United States consists of 4.6% the world s population and yet we consume 80% of the world s opioids (Solanki, Koyyalagunta, Shah, Silverman, & Manchikanti, 2011)

10 Hormonal Imbalance-A decrease in GNRH lowers sex hormone levels for both men and women. These low hormone levels will occur in over 50% of people on chronic opioid therapy (Reddy, Aung, Karavitaki, & Wass, 2010). Persistent low sex hormone levels produce multiple symptoms, which may include loss of libido, infertility, fatigue, depression, anxiety, loss of muscle strength and mass, alteration of gender role, osteoporosis, and compression fractures and, in men, impotence, and, in females, menstrual irregularities, galactorrhea and infertility (Katz, 2005) Sleep disorders Depression / Worsening of Mental illness Failure to inform patients of the risk of driving while taking a medication, such as a benzodiazepine, may lead to a claim of negligence against the prescribing Physician / Medical Provider. Given the liability risks, Providers should apprise patients of these concerns and document this in the medical record. FORMULATE & UTILIZE A TREATMENT CONTRACT When a controlled substance is being considered as a treatment option, patients should be informed of the potential for physical dependency and the possibility of mild to moderate rebound effects even with gradual tapering. The physician / medical provider should carefully review the benefits and risks of the chosen medications, as well as other treatment choices. Formulate a Treatment Contract for all controlled drugs % of the population use benzodiazepines within the course of a year for most the use is short term, two-thirds 60 days or less: Acute Insomnia / Chronic Insomnia * Medical / Psychiatric Patients recurrent dysphoria * Anxiety / Panic / Agoraphobia * Agitation Geriatric associated with Medical Illness / Mental Illness* Pre-Medication for Surgery Procedural Anesthesia Convulsive Disorders Alcohol or drug detoxification Muscle spasm Off Label Adjunctive Medicine for additional Pain relief-avoid Long Term > 1 Year *: 1-2% of the population taking benzodiazepines on a long-term basis. Daily or Nightly, Most patients do not lose control of their use. ( these drugs can cause Cognitive Impairment, Worsen / Cause Dementia- Depression, Overdose, Falls, Amnesia, Cognitive Impairment, Dependence & Addiction ) A problematic pattern of Sedative Hypnotic Anxiolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12 month period: 1. Impaired Control: Sedatives Hypnotics or anxiolyticss are often taken In larger amounts or over a longer period then was intended.* 2. Impaired Control: There is a persistent desire or unsuccessful efforts to cut down or control sedatives hypnotics anxiolytics use.* 3. Impaired Control: A great deal of the time is spent in activities necessary to obtain the sedatives hypnotics anxiolytics : use the sedatives hypnotics or anxiolytics; or recover from its effects.* 4. Impaired Control: Craving, or strong desire or urge to use sedatives hypnotics anxiolytics.*** 5. Social Impairment: Recurrent sedative hypnotic anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home..** 6. Social Impairment: Continued sedative hypnotic anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedative hypnotic anxiolytic.** 7. Social Impairment: Important social, occupational, or recreational activities are given up or reduced because of sedative hypnotic anxiolytic use.* 8. Risky Use: Recurrent sedative hypnotic anxiolytic use in situations in which it is physically hazardous.** 9. Risky Use: Sedative hypnotic anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative hypnotic anxiolytic.** 10. Pharmacologic Properties: Tolerance, as defined by either for the following: * a) A need for markedly increased amounts of sedative hypnotic anxiolytic, to achieve intoxication or desired effect. b) A markedly diminished effect with continued use of the same amount of the sedative hypnotic anxiolytic. Note: This criterion is not considered to be met for those taking opioids, solely under appropriate medical supervision 11. Pharmacologic Properties: Withdrawal, as manifested by either of the following: * a) The Characteristic sedative hypnotic anxiolytic withdrawal syndrome. b) Sedatives Hypnotics Anxiolytics are taken to relieve or avoid withdrawal symptoms. Note: This criterion is not considered to be met for those individuals take opioids solely under appropriate medical supervision. Severity criteria: 2-3 mild, 4-5 moderate, 6 or more severe * DSM-IV Dependence **DSM-IV Abuse ***DSM-5 addition ( Formerly DSM-IV 59 Use is FDA off-label Useful and adjunctive medication, resulting in decreased action potential for relief of skeletal muscle spasms due to reflex spasm to local pathology. Mechanism of action GABA receptors. Small study of 21, female patients. 62% were responders, moderate to marked improvement. 38%, no change 60 10

11 Benzodiazepines, all for almost immediate symptomatic relief or anxiety, can be quite appealing for many patients and clinicians. Before benzodiazepines, alcohol, and opiates were used for Centuries to numb anxiety. Early in the 20 th Century, barbiturates were prescribed for Sedative, Anxiety, Insomnia,Later for Anticonvulsant effect & concerns arose for risk of addiction & death from overdose. Meprobamate was introduced in 1955 and became an overnight sensation, the first psychotropic wonder drug in medical history. However, that success was nothing compared with the todays view of benzodiazepines, beginning with chlordiazepoxide ( Librium,Limbitrol ) in Valium, diazepam ). For many years benzodiazepines were among the most frequently prescribed medications in United States. APA Task Force for benzodiazepines reported in 1990 that benzodiazepines were affective medications with mild adverse effects and low potential for abuse when prescribed properly. The year before 1989, New York State and that benzodiazepines should be dispensed as control substances. Benzodiazepines bind stereo -specifically to portions of GABA receptors that her large protein complex located on certain Neurons in the CNS. Physical Dependence- Rebound, Recurrence & Withdrawal Symptoms. 1. Worse anxiety, restlessness, insomnia ( short t ½ drugs, these symptoms may appear between dosing, other withdrawal symptoms are what the drug was intended to relieve ) 2. Withdrawal Symptoms-see above symptoms ( +headache, crawling Skin symptoms, Agitation, Nausea / Vomiting, Adrenergic drive Symptoms ), Psychosis-Hallucinations & Withdrawal Seizures. The APA guidelines for the treatment of panic disorder activities to use of SSRIs, reserving benzodiazepines for the management of acute anxiety rather than for long-term treatment. With a moderate increase in SSRI use for panic disorders took place during the 1990s, more than thirds of this increase occurred as a part of concomitant treatment with a benzodiazepine. Pomerantz, risk vs benefits of benzodiazepines Pomerantz, risk vs benefits of benzodiazepines The principal indication for BZDs is for short term treatment (2 to 6 weeks) of anxiety disorders. These conditions include generalized anxiety disorder, phobias, PTSD, panic disorder, and severe anxiety associated with depression, while waiting for the full effect of the antidepressant. Continuing BZDs beyond 4 to 6 weeks will result in loss of effectiveness, the development of tolerance, dependence and potential for withdrawal syndromes, persistent adverse side effects, and interference with the effectiveness of definitive medication and counseling. BZDs taken for more than 2 weeks continuously should be tapered rather than discontinued abruptly. There is evidence for the effectiveness of BZDs and other hypnotics in the relief of short term (1 to 2 weeks), but not long term, insomnia. The treatment period should not exceed 2 weeks. BZDs may be used for longer than 6 weeks in the terminally ill, in the severely handicapped patient, in certain neurological disorders (stiff person syndrome), and as an alternative to antipsychotics in the severely demented patient. There is no evidence supporting the long term use of BZDs for any mental health indication. At the time of BZD prescription renewal or medication review, the physician should discuss the risks of long term BZDs and the benefits of discontinuation (on cognition, mood, sleep, and energy level) and advise the patient to reduce or discontinue the BZD. For some patients this will be difficult or impossible, but the effort should be made. For many a reduction in dose, rather than discontinuation, will be the goal. After many years of successful bariatric weight loss surgeries directed at the obesity epidemic clinicians are reporting that some patients are replacing compulsive overeating with newly acquired compulsive disorders such as alcoholism, gambling, drugs, and other addictions like compulsive shopping and exercise. Reward Deficiency Syndrome (RDS) 4 chronic genetic determinants in predicting an active disorders and reported that her predicted value for future RDS behaviors and subjects carrying the DRD2 Taq A1, allele 74%. Polly Genes play a role in RDS, we also referred that disruptions in dopamine function may predispose certain individuals to addictive behaviors and obesity. It is now known family history of alcoholism is a significant obesity, risk factor, hypothesis suggests That RDS is the cause of substituting food addiction for opiate dependency and potentially explains that recently described phenomenon (Addiction Transfer ), and after bariatric surgery. Neuro-Genetics of Reward Deficiency Syndrome as the root cause Of Addiction transfer, NIH Several recent studies reported decrease in mortality and severity medical conditions after bariatric surgery. However, long-term effects are not clear. In the Swedish prospective matched controlled trial, patients with BMI of 34 or more for men and 38 or more for women underwent various types of bariatric surgery and were followed for an average of 11 years. 1. Surgery patient had a 23.7% reduction in mortality. 2. This means 75 patients must be treated to avoid one death after 11 years. In the Utah retrospective cohort study that followed patients for an average of 7 years after various types of gastric bypass, surgery patient s had 0.4% mortality well-controlled patient 0.6% daily. However, death rates were lower in the gastric bypass patient s oral disease is combined, as well as for diabetes, heart disease, and cancer.on the other hand, deaths from accident and suicide were 58% higher in the surgery. Gold s Group, have hypothesized that drugs of abuse compete with food for brain reward sites. I report, an inverse relationship between the presence of co-morbid overweight/obesity and substance use disorders in bipolar 1 disorder. Also, this group found as a BMI increases, lower rate of alcohol consumption are found in women. Overeating may compete with alcohol for brain reward sites, making alcohol ingestion less reinforcing. Other researchers conclude back and whole metabolism was significantly different between the post gastric bypass, and control subjects. The gastric bypass patient s had a greater peak alcohol level and a longer time for the alcohol level to reach 0 than the controls. These findings provide caution regarding alcohol use by gastric bypass patient s with altered alcohol metabolism. Neuro-Genetics of Reward Deficiency Syndrome as the root cause Of Addiction transfer, NIH Neuro-Genetics of Reward Deficiency Syndrome as the root cause Of Addiction transfer, NIH

12 Substance- abuse centers, including the Betty Ford Center in Ranch Mirage, California, are seeing more bariatric-surgery patient s checking in for help with new addictions. And alcohol use has become a topic of discussion on bariatric-surgery-support sites, such as Weight Loss Surgery Center. In unpublished statement at the Betty Ford Center, about 25% of alcohol relapse which to a new drug, such as opiates. While still controversial the conversion rate to other dependencies vary from only 5% to 30%. For decades, the conventional wisdom and clinical lore in rehab facilities and recovery communities has warned against the risks of so-called "cross-addiction. But is it even true? According to a new report, published September 10 in JAMA Psychiatry, the answer is a resounding, "No. The study, "Testing the Drug Substitution Switching-Addictions Hypothesis," analyzed data from the National Epidemiological Study on Alcohol and Related Conditions (NESARC) to investigate whether participants developed new-onset substance use disorders (SUD) after remission from a previous SUD. These data were then compared against people with a SUD who did not achieve remission but also developed a new-onset SUD. The authors discovered that, "As compared with those who do not remit from an SUD, remitters have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution but rather is associated with a lower risk of new SUD onsets. Those who do not remit, have 1 in 5 chance of new onset SUD. Seabrook House s Mission is to continue to educate our Patient s on the danger of using medications with sedative properties that could potentially cause a relapse. Neuro-Genetics of Reward Deficiency Syndrome as the root cause Of Addiction transfer, NIH 67 Most patients who take prescribed narcotic analgesics, sedative hypnotics or stimulants, Which have abuse potential, use them responsibly and as directed. Drugs of this type generate scrutiny from the U.S. Drug Enforcement Agency (DEA) and other authorities because of there abuse Potential, overdose issues, and potential for illegal distribution. Two of the most common reasons that people consult a Physician / Medical Provider Are Pain & the Somatic Manifestations of Anxiety. Failure to provide relief from pain and anxiety disorders exacts an enormous social cost from lost productivity, needless suffering and excessive health care expenditures. With the advent of pain as the 5 th Vital sign and the side effects of NSAIDs Including GI bleeding and Cardiovascular issues. This lead to increased prescribing of opiates. Overprescribing ( Stimulants + opiates+ Benzodiazepines ) is the leading cause of investigations of Physicians / Medical Providers and of actions against the Providers licenses. Patient satisfaction takes on even greater importance as ACA provisions set to begin October 1, 2012, tie patient satisfaction to Medicare reimbursement, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey Patients who abuse prescription drugs may exhibit patterns, such as: escalating use drug-seeking behavior doctor shopping Physicians / Medical Providers must say NO and stick with it when patients exert pressure to obtain a prescription drug. Medical Providers who overprescribe can be characterized by the four Ds : Dated Duped Dishonest Disabled Maintaining a current knowledge base, documenting the decisions that guide the treatment process and seeking consultation are important risk management strategies that improve clinical care and outcomes. The street value of controlled prescription drugs has been estimated by the DEA to be second only to the street value of cocaine, and greater than the street value of marijuana and heroin. Paradox for Physicians/ Medical Providers: the desire to relieve pain, anxiety and other discomfort must be weighed against the fear of creating addiction, of being investigated by law enforcement or licensing authorities, and of being scammed by the occasional patient who abuses opioid analgesics, sedative hypnotics or psychostimulants. These competing concerns often leave Providers feeling uncomfortable about prescribing controlled substances, to the detriment of the majority of patients who suffer legitimate illnesses and are often left undertreated or feeling stigmatized

13 Why Should I Care? Excessive alcohol use is the 3 rd leading cause of preventable death in the US. Tobacco is the leading cause of preventable death in the US. Illegal drug use is alarmingly prevalent: Around 9% of the population aged 12 or older reports using illegal drugs within the past month (SAMHSA 2010). Approximately 8.9% of the population over 12 met DSM-IV criteria for substance abuse or dependence (substance use disorder in DSM-5) Why should you make this change to your practice? SBIRT is an evidence-based best practice that is strongly supported in the literature. For example, in one study, 6 months following SBIRT interventions: Rates of illicit drug use were 67.7% lower (p<0.001). Rates of heavy alcohol use were 38.6% lower (p<0.001). Success was seen across clinic settings, gender, race/ethnic, and age subgroups. (Madras et al. 2009) To Test the efficacy of 3 interventions 1. Screening / referral to treatment 2. Screening, brief intervention, and facilitated referrals to community-based treatment. ( brief intervention ). 3. Screening, brief intervention, ED-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10 week follow up ( buprenorphine). Conclusion: Among Opioid dependent patients, ED-initiated buprenorphine Treatment vs brief intervention and referral significantly increased engagement in addiction treatment, reduced self reported illicit opioid use, and decreased use of inpatient addiction treatment services but did not significantly decrease the rates of urine samples that tested positive for opioids or HIV risk. These findings require replication in other centers before widespread adoption. Jama 2015, 313(16): dbi /jama Box 6 Risk Level Intervention AUDIT score* Zone I Alcohol Education 0-7 Zone II Simple Advice 8-15 Zone III Zone IV Simple Advice plus Brief Counseling and Continued Monitoring Referral to Specialist for Diagnostic Evaluation and Treatment

14 The patient who has been diagnosed with substance abuse should be referred to an addiction-medicine specialist or an inpatient or outpatient treatment center. These steps give the patient a solid start on the recovery process. It is possible to detoxify the patient on an outpatient basis. The patient then can be referred to Alcoholics Anonymous or Narcotics Anonymous for sustained follow-up support. Whatever treatment the patient undergoes, it is important for family physician to be supportive of the patient and the family in recovery. Physicians should be careful about prescribing moodaltering drugs. The Medical Practitioner can play a pivotal role by dealing with the patient and family in a nonjudgmental manner