Substance Use and Addiction. Presentation for Physicians and Other Health Care Providers JOHN HARSANY JR. M.D. F.A.S.A.M.

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1 Substance Use and Addiction Presentation for Physicians and Other Health Care Providers JOHN HARSANY JR. M.D. F.A.S.A.M.

2

3 Addiction Medicine The specialty of medicine devoted to diagnosis, treatment, prevention, education, epidemiology, research, and public policy advocacy regarding addiction and other substance-related health conditions

4 4

5 ADDICTION IS A BRAIN DISEASE THE ADDICTED-BRAIN SYNDROME

6 ADDICTION 1. PHYSIOLOGICAL: (PHARMACOTHERAPY) ANTI-CRAVING--- FOCUS 2. PSYCHOLOGICAL: A. C.B.T. B. M.E.T. C. T.S.F. D. H.T.H. E. ADJUNCT-Rx

7 Reward pathway

8 ADDICTION IS A BRAIN DISEASE & A NATIONAL CONCERN ALCOHOL = 24 MILLION NICOTINE = 46 MILLION OPIATES = 8 MILLION GAMBLING = 22 MILLION PRESCRIPTION MEDS = 32 MILLION PROCESS ADDICTIONS = 24 MILLION

9 ADDICTION A.USE B.MISUSE C.ABUSE D.HABITUATION E.DEPENDANCE F.ADDICTION

10 STOOL STOO OF RECOVERY P R O G R A M

11 TREATMENT TRIANGLE A. PHYSICIAN PATIENT WITH ADDICTED BRAIN SYNDROME B. PSYCHO-THERAPIST C. PHARMACIST

12 Prescription Drug Abuse: Scope of the Talk What and which drugs? Why now? Who abuses prescription drugs? What can we do?

13 Definitions: What s abuse behavior to us? Any non-prescribed use of a drug (NIDA, 2002 & DEA, 1970) Non-medical use of a substance for psychic effect, dependence, or suicide attempt or gesture (SAMHSA, 2002) Any harmful use, irrespective of whether the behavior constitutes a disorder in the DSM-IV diagnostic nomenclature (IOM, 1996) A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by one or more behaviorally-based criteria (APA, 1994)

14 Drugs of Abuse: Not Just Opioids Opioids and other pain killers Stimulants Anti-anxiety drugs Sedative/hypnotics Feel good drugs (antidepressants) Look good drugs (steroids) Feeling goofy drugs (psychedelics)

15 Pain Prescription Abuse In 2002, nearly 30 million people over 12 used prescribed pain relievers nonmedically 15 million dependent/abused prescribed pain relievers; 2 nd. only to marijuana

16 Under the Counter July 7, 2005 CASA More than 15 million American abuse Opioids, Depressants & Stimulants in 2003 Rx abuse among teens triple in 10 years From 1992 to 2003, abuse of controlled Rx drugs grew at the rate 2x that of marijuana; 5x that of cocaine; 60x that of heroin In 2003, 2.3 million teens y.o. (1/10) abused a controlled Rx, 83% opioids ER visits related to opioid medication more than doubled between 1994 and 2001 (DAWN 2002)

17 Commonly Abused Opioids Diacetylmorphine Hydromorphone Meperidine Hydrocodone Oxycodone Heroin Dilaudid Demerol Lortab, Vicodin OxyContin, Percodan, Percocet, Tylox

18 Oxycodone and Oxycodone CR Oxycodone: OxyIR, Roxycodone Acute pain 4-6 hrs duration of action Tabs, caps, liquid Oxycodone CR: Oxycontin Chronic pain; already tolerant to opioids 12 hrs duration of action Not for prn use Tablets only

19 Emergency Dept. Mentions Of Single-Entity Oxycodone ,996 11,100 3,792 1, National Survey on Drug Use and Health (NSDUH), SAMHSA, Sept 5, 2003

20 Increased Media Attention

21 Oxycontin

22 Easy Access: Role of the Internet? Delivered in the Privacy of your Home Some reasons why you should consider using this pharmacy No prescription required!

23 Prescription Abusing Populations Prescription drug abusers Youths, elderly, women, minorities Pain patients who abuse opiate medication Users with co-morbid psychiatric conditions Substance abusers Prescription drugs only Prescription drugs plus other substances such as heroin (polydrug abusers)

24 Youth Prescription Abuse Youth obtain prescription opioids from peers family and friends Fastest growing prescription abuse group Females users out number males Prevention programs don t work Not reached by treatment programs Largely unknown later consequences

25 The Elderly Prescription Opioid Abuser Multiple medical problems Higher incidence of chronic pain Misunderstand directions: misuse vs abuse Multiple prescribers Rationalization and denial among family members, peers or care providers Deficits presumed to be due to age Interaction with alcohol or other drugs Over representation of females

26 Women and Prescription Drug Abuse Similar rates as men More likely to use abusable prescription drugs, especially opioids and anxiolytics 2-3 x more inclined to be diagnosed with depression and given more psychotherapeutics Twice more prone to be addicted to drugs Combine with alcohol more often More elderly women, more prescriptions

27 Women and Prescription Drug Abuse 4 million women abuse prescription drugs Among year olds female surpass males in use of cigarettes, cocaine, inhalants and prescription drugs Women account for 60% of ER visits for prescription drug abuse

28 Prescription Drug Abuse in Pain Patients Complex relationship between drug abuse and use of opioids in pain management Overlapping vulnerability and psychopathology Somatoform pain disorders Consumption of other substances Iatrogenic factors Uncritical prescribing, inadequate monitoring, absence of functional improvement Inadequately treated pain J Jage Euro J Pain :

29 Increased prescription of opioids has resulted in increased opioid analgesic abuse (Gilson et al., 2004) Medical use Abuse Oxycodone % % Fentanyl % % Hydromorphone 96.35% % Morphine 73.30% % Meperidine -6.13% %

30 The Fateful Triangle: Opioids, Pain and Addiction Under treatment of pain Increasing availability of opioid analgesics Increase in abuse of prescription opioids

31 Opium Lull all pain and anger, and bring forgetfulness of every sorrow. - Odyssey Among the remedies which it has pleased Almighty God to give to man to relieve his suffering, none is so universal and so efficacious as opium. - Thomas Syndenham, 1680

32 Opium It banishes melancholy, begets confidence, converts fear into boldness, makes the silent eloquent and bastards brave John Brown

33 From Pain Relief to Addiction: Role of the Opiates Relieve pain Relieve pain and suffering Relieve suffering and misery Make you feel better Make you feel good Make you high

34 Characterizing Pain Pain: An unpleasant sensory and emotional experience arising from the actual or potential tissue damage or described in terms of such damage. It is always subjective. Each individual learns the application of the word through experiences related to injury in early life. IASP

35 Acute vs Chronic Pain Acute pain is for survival Chronic pain serves no purpose Sufferers of chronic pain suffer for nothing Concern in acute pain: what pain does the patient have? Concern in chronic pain: what patient does the pain have?

36 Chronic Pain and Addiction: Common Features Chronic pain Early trauma Loss of mastery Loss of control Loss of sense of self Cognitive error personalization Over interpretation catastrophy Addiction Early trauma Loss of mastery Loss of control Loss of self efficacy Cognitive error nirvana Denial

37 Who s at Risk and How to Tell? Four ways to identify patients at risk: History: personal history & family history Screening instruments Behavioral check lists Therapeutic maneuver

38 History What predicts addiction? Personal history of drug abuse Family history of drug abuse Current addiction to alcohol or cigarettes History of problems with prescriptions Co-morbid psychiatric disorders Same predictors as in non-pain patients

39 Ongoing Warning Signs Altered/forged prescription Theft of prescription pads Frequent requests to move appointments up Keep pain appointments; miss others Grossly disheveled/impaired Request early refills/frequent phone calls Lost/stolen prescriptions Frequent unauthorized dose escalations Positive urine tests for illicit drugs

40 Is the pain patient addicted? ( Drug-seeking Addiction) Drug-seeking or increased requests for pain medication Detailed pain work-up opioid dose pathology/pain of new source No new pain pathology Unimproved functioning Presence of toxicity Addictive disease Improved functioning Absence of toxicity pseudoaddiction therapeutic dependence

41 Can Addicts be Treated with Opiates? Yes, but with caution Increase recovery activities Provide support systems Treat co-morbidity Remember Non-opioid analgesics Non-pharmacological treatments Cognitive behavior therapies

42 Treating Pain with Opioids: What Can We Expect to Achieve? Reduction in pain and suffering Meaningful pain reduction Improved functionality Meaningful improvement in activities

43 Meaningful Functional Improvement: My Favorites Patient perspective of improvement Used to do, can t do now, would like to do again Could be physical, social, recreational With friends, family, church Achievable, enjoyable and meaningful Hobbies Volunteer work

44 Conclusion: Prescription Drug Abuse Escalating problem Heterogeneous population Youth Elderly Women and minorities Chronic pain patients Pain and addiction complex disorder

45 Acknowledgment and Thanks Conference organizers Friends and colleagues: Dr. Walter Ling NIDA You the audience My Son: Scott Harsany of H.P.

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