Fundaments of Addiction Medicine. Addiction Medicine Express All of Addiction Medicine in 60 Slides and 60 minutes

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1 1:15 2:3 pm Addiction Medicine Express SPEAKER Petros Levounis, MD, MA Presenter Disclosure Information The following relationships exist related to this presentation: Petros Levounis, MD, MA: No financial relationships to disclose Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Addiction Medicine Express All of Addiction Medicine in 6 Slides and 6 minutes Petros Levounis, MD, MA Chair, Department of Psychiatry Rutgers New Jersey Medical School Learning Objectives 1. Apply neurobiological concepts to treat patients who suffer from substance use disorders 2. Identify intoxication and withdrawal syndromes of alcohol, opioids, and sedatives 3. List three psychosocial and three pharmacological interventions in the treatment of addiction Outline A. Fundamentals of Addiction Medicine B. Assessments and Treatments C. Special Populations and Topics A Fundaments of Addiction Medicine

2 NEUROBIOLOGY OF ADDICTION Natural Rewards and Dopamine Levels Biological Psychological Social Use Brain Switch Addiction % of Basal DA Output Food 15 1 Empty 5 Box Feeding Time (min) DA Concentration (% Baseline) 15 1 Sex Female Present Sample Number Adapted from: Di Chiara, Neuroscience, 1999; Fiorino and Phillips, J Neuroscience, % of Basal Release % of Basal Release 25 Effects of Drugs on Dopamine Levels MORPHINE Dose mg/kg hr NICOTINE % of Basal Release % of Basal Release COCAINE hr ETHANOL Dose (g/kg ip) ALCOHOL GABA CNS Inhibition Glutamate CNS Excitation Opioid Euphoria Dopamine Addiction Serotonin Impulsivity Cannabinoid Pleasant Feeling hr hr Adapted from: Di Chiara and Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D Volkow, MD. Alcohol Intoxication -1 mg/dl Well-being 1- mg/dl Incoordination -3 mg/dl Ataxia 3-4 mg/dl Stage I Anesthesia 4-6 mg/dl Coma 6-8 mg/dl Death Treat supportively. Alcohol Withdrawal Following the last drink: 6 to 24 hours: Autonomic Hyperactivity 24 to 48 hours: Seizures 48 to 96 hours: Delirium tremens Typically mild, occasionally severe, rarely fatal. Treat with: Mild: Moderate: Severe: Hydration and Rest Oral Chlordiazepoxide (CIWA Protocol) IV Chlordiazepoxide in ICU

3 Alcohol Addiction Dislufiram Naltrexone Acamprosate OPIOIDS 1. Naturally Occurring Opioids Morphine Codeine 2. Semi-Synthetic Opioids Oxymorphone Oxycodone Hydromorphone Hydrocodone Di-Acetyl-Morphine (Heroin) 3. Synthetic Opioids Fentanyl Methadone (Tramadol) Buprenorphine Opioid Intoxication 1. Constricted pupils 2. Constipation 3. Nausea and vomiting (often projectile) 4. Respiratory depression 5. Coma and death Treat with naloxone. Opioid Withdrawal 1. Dilated pupils 2. Diarrhea 3. Flu-like symptoms (rhinorrhea, lacrimation) 4. Yawning 5. Unbearable body aches 6. Sweats and piloerection ( cold turkey ) Treat with methadone or buprenorphine. Opioid Addiction STIMULANTS COCAINE Inhibits Reuptake of synaptic dopamine METH Inhibits Reuptake of synaptic dopamine Promotes Direct dopamine release

4 Stimulant Acute States Stimulant Addiction Intoxication: 1. Euphoria 2. Hypervigilance to frank paranoia 3. Decreased appetite 4. Seizures Withdrawal: 1. Dysphoria 2. Psychomotor retardation 3. Increased appetite Dackis, J Subst Abuse Treat, 212. Please note: This agent is not approved by the FDA for use in cocaine use disorder. CANNABIS Cannabis Acute States Intoxication: If drunk you run the RED lights If stoned you stop at the GREEN lights Withdrawal: Withdrawal syndrome is not: As painful as heroin withdrawal, As dangerous as alcohol withdrawal, or As long-lasting as cocaine withdrawal NSDUH, TEDS, National Seizure System. Cannabis Addiction Therapeutic Potential Pain (cancer, multiple sclerosis) Nausea (cancer) Loss of appetite and wasting (HIV/AIDS) Increased ocular pressure (glaucoma) Inflammation (rheumatoid arthritis, Crohn s disease, ulcerative colitis) Epilepsy Meier, Proc. Natl. Acad. Sci., 212. Volkow, NEJM, 214.

5 TOBACCO Tobacco Addiction Individuals with mental illness or substance use disorders AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced Centers for Disease Control and Prevention, NHIS, 7. Anthenelli, Lancet, 216. BEHAVIORAL ADDICTIONS Both impulsivity and compulsivity show inability to refrain from dysfunctional repetitive behaviors. Impulsivity is driven by an effort to obtain arousal and gratification (norepinephrine and dopamine). Compulsivity is driven by an effort to reduce anxiety (serotonin). Dimensional Approach COMPULSIVE END OCD Body Dysmorphic Disorder Anorexia Nervosa Hypochondriasis Tourette s Syndrome Trichotillomania Autism Binge Eating Compulsive Buying Kleptomania Pathological Gambling Self-Injurious Behaviors Sexual Compulsions Borderline Personality Disorder IMPULSIVE END Antisocial PD Hollander and Stein, Clinical Manual of Impulse-Control Disorders, 6. SSRIs for Alcohol Use Disorder The Behavioral Addictions in 216 6% 5% 4% 3% 2% 1% % Early (n=45) Placebo Late (n=55) Sertraline Abstinence rates during a 14-week treatment trial with sertraline mg QD. Sertraline helped Late- Onset alcoholics stay abstinent, but worsened the condition for Early-Onset alcoholics. 1. Exercise 2. Food 3. Gambling 4. Internet Gaming 5. Internet Surfing 6. Texting and ing 7. Kleptomania 8. Love 9. Sex 1. Shopping 11. Tanning 12. Work Pettinati, Alcohol Clin Exp Res,. Ascher and Levounis The Behavioral Addictions, American Psychiatric Publishing, 215.

6 B Assessments and Treatments SIX TIPS FOR RECOGNIZING ADDICTION 1.Moody 2.Changes in Sleep 3.Changes in Appearance 4.Work Performance 5.Financial Difficulties 6.Abusive Behavior GetHolisticHealth.com SIX TIPS FOR TREATING ADDICTION 1.Alcohol AA 2.Opioids Buprenorphine 3.Stimulants CBT 4.Cannabis MI 5.Tobacco Varenicline 6.All Other CBT SCREENING For Alcohol Use Disorders MEN: 5 or more standard drinks in a sitting. (15 or more per week.) WOMEN: 4 or more standard drinks in a sitting. (8 or more per week.) NIAAA.NIH.gov. Toxicology Urine Toxicology Detection Limits Alcohol Alcohol (Ethyl glucuronide, EtG test) Amphetamines/Methamphetamines Benzodiazepines (Short-acting) Benzodiazepines (Long-acting) Cocaine Heroin (Morphine) Methadone Marijuana (Single use) Marijuana (Long-term heavy use) 7-12 hours 4 days 2 days 3 days 3 days 2-4 days 2 days 3 days 3 days >3 days Adapted from: Staub, Clinical Chemistry, 1. Moeller. Mayo Clin Proc. 8; Anders, et al. Alcohol and Alcoholism, 9.

7 The DSM-5 PHYSIOLOGY The Tolerance Wise Withdrawal THE CORE PROBLEM OF SUBSTANCE USE Know: Knowledge of adverse consequences, yet continued use INTERNAL PREOCCUPATION Decline Desire to cut down Tender Time a great deal of time spent using Loving Larger amounts or longer periods of use than intended Care, Craving EXTERNAL CONSEQUENCES And Activities given up Respect Role obligations neglected Silver Social or interpersonal problems Hair. Hazardous use Levounis. Academic Psychiatry, 215. Substance-Related and Addictive Disorders Alcohol Caffeine Cannabis Hallucinogen Inhalant Opioid Sedative Stimulant Tobacco Gambling Disorder BRIEF INTERVENTION 12-Step Facilitation 1. Be empathic and curious. 2. State your medical findings. 3. Educate about problematic use and addiction. 4. Advise. 5. Follow up. 6. Refer, if necessary. Attitudes and Perceptions MEDICAL STAFF 1. Housing 2. Gov t Services 3. Medical Services 4. Outpatient Tx 5. Job 6. Community 7. Trusting People 8. Inner peace 9. God 1. Spirituality 11. AA PATIENTS 1. Inner peace 2. God 3. Medical Services 4. AA 5. Housing 6. Spirituality 7. Outpatient Tx 8. Community 9. Gov t Services 1. Trusting People 11. Job What Medical Staff Think Patients Think 1. Housing 2. Outpatient Tx 3. Medical Services 4. Job 5. Trusting People 6. AA 7. Inner Peace 8. Community 9. Gov t Services 1. Spirituality 11. God Cognitive Behavioral Therapy 41 Goldfarb, Am J Drug Alcohol Abuse, Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 21.

8 Motivation and Mindfulness Psychiatric Co-Morbidities 1. A third to two thirds of addicted people also suffer from another mental illness not 1%, not 9%. 2. Treat both the addiction and the cooccurring psychiatric disorder(s). 3. Avoid benzodiazepines and use antidepressants as first line treatments for anxiety disorders. Genetics C Special Populations and Topics Di Forti, Biol Psychiatry, 212. Pregnancy Adolescence Jones, N Engl J Med, 21. MonitoringTheFuture.org; Volkow, NEJM, 214.

9 The Elderly The Current Opioid Epidemic 1 1. Addiction is grossly underdiagnosed due to: Reduction in everyday expectations resulting in decreased transgressions Societal stereotype of an addict as a young person Lack of peer group surveillance 2. Sedative and opioid drug-drug interactions are particularly prevalent. Porter and Jick, N Engl J Med, January 1, 198. The Current Opioid Epidemic 2 The Current Opioid Epidemic 3 Compton, N Engl J Med, 216. EMERGING TRENDS Bath Salts % reporting any substance use disorders And Back to Psychodynamics * 11.4 *** *** 13.2 * 9.6 Ref 5.6 Women 17.7 Only same-sex Mostly same-sex Equally both sexes Mostly 18.5other sex Only other 15.7 sex 12.2 Men *p<.5, ***p<.1 based on logistic regression analysis adjusted for race, age, educational level, personal income, employment status, relationship status, health insurance status, geographic location, MSA, age at alcohol onset, and family history of AOD problems. Reference group was heterosexual group. En.Wikipedia.org Courtesy of Sean McCabe, PhD.