COMMON ADDICTIONS IN OUR Punta Cana 2018

Transcription

1 COMMON ADDICTIONS IN OUR Punta Cana 2018

2 Copyright 2017 by Sea Courses Inc All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 CFPC CoI Templates: Slide 1 Faculty/Presenter Disclosure Faculty: JOEL BORDMAN Relationships with commercial interests: Grants/Research Support: N/A Speakers Bureau/Honoraria: Purdue, Indivior, OCFP, MedPlan, ECHO Consulting Fees: OCFP, CMPA, CNO, ONA, Purdue, Indivior, Other:

4 CFPC CoI Templates: Slide 2 Disclosure of Commercial Support This program has received financial support from SEA COURSES in the form of Honoraria. This program has received in-kind support from Sea Courses in the form of logistical support. Potential for conflict(s) of interest: Joel Bordman has received honoraria from Purdue, Indivior [Purdue, Indivior benefits from the sale of products that will be discussed in this program: Suboxone (Buprenorphine/Naloxone), OxNeo (Oxycodone LAresistant to crushing), HydroMorphContin (Hydormorphone LA)

5 CFPC CoI Templates: Slide 3 Mitigating Potential Bias Every effort will be made to remind audience of potential bias throughout the presentation

6 Objectives To review basic traits that expose certain individuals to certain addictive substances To review the harms and consequences to exposure to a few of the common addictive substances

7 SNOW WHITE AND HER 7 FRIENDS WITH ADDICTION JOEL BORDMAN, M.D.

8 Full Disclosure This concept may be plagiarized. But I don t know from who, when or where.

9 A LOOK AT OTHER SUBSTANCE ADDICTIONS SNOW WHITE AND HER 7 FRIENDS: BASHFUL DOC DOPEY GRUMPY HAPPY SLEEPY SNEEZY 9

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11 Sleepy... Benzodiazepines Mechanism of action: GABA, promotes direct opening of Chloride channels Medical use Anxiety disorders Muscle relaxants Anticonvulsants Alcohol withdrawal

12 Benzodiazapines Problems: Anterograde amnesia Elderly: exacerbate dementia, falls Exacerbate anxiety and depression with chronic use Life threatening seizures with withdrawal

13 If Tapering Benzo s, some good references: (The Ashton Manual) Canadian pain guidelines

14 General principles around tapering Benzos Provide informed consent re: Benzo + / - ( But I ve been on them for 30 years ) Approach: Usually slow is more effective. Adjust taper to circumstances Scheduled better than PRN Long acting may be better than short acting (dose equivalent tables) See every 1-4 weeks (ask about BENEFITS of tapering)

15 Sleepy #2...Barbiturates Very narrow therapeutic index Less common than in 1960 s Mothers Little Helper (Rolling Stones) Kids are different today, I hear every mother say Mother needs something today to calm her down And though she's not really ill, there's a little yellow pill She goes running for the shelter of a mother's little helper And it helps her on her way, gets her through her busy day

16 Dopey... Marijuana Medical uses: Increased appetite Anti-nauseant Analgesic A good Canadian resource:

17 Pharmaceutical Cannabinoids Nabilone 0.5, 1.0mg BID cancer chemo nausea and vomiting THC / CBD spray MS neuropathic pain severe cancer pain on opioids

18 Thoughts. Are we in a Catch-22 situation with Cannabiniod research?

19 Cannabis as an Analgesic? Human evidence is very limited thus far 4 published RCTs smoked cannabis (Abrams 2007; Ware 2010) Smoking is a dirty way to give a drug In palliative care may not be a concern 1 published RCT on nabilone in FM pain (Skrabec, 2007) There may be a dose window for pain (Wallace, 2007) Adverse effects: CNS depression, psychosis, ataxia, disorientation, addiction, effects on memory and motor function, decreased IQ, gateway drug Abrams et al. Neurology 2007; 68(7): Aldington et al Thyorax 2007; 62(12): Broadbent et al. JAMA 2008; 299(5): Wallace et al. Anesthesiology 2007; 107(5): Ware et al. CMAJ 2010; 182(14):

20 Legalization and Opioid Overdose Mortality Three states (California, Oregon, and Washington) had medical cannabis laws effective prior to Ten states (Alaska, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and Vermont) enacted medical cannabis laws between 1999 and 2010 States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate (95%CI, 37.5%to 9.5%; P =.003) compared with states without medical cannabis laws The lower rate of overdose mortality strengthened over time Year 1 ( 19.9%; 95%CI 30.6%to 7.7%; P =.002) Year 6 ( 33.3%; 95%C, 44.7%to 19.6%; P <.001) Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, , Marcus A. et al. JAMA Intern Med. 2014;174(10): , Aug 25, 2014

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23 Crane et al: episodic memory Evidence of problems with episodic memory is one of the most consistent findings reported Episodic memory is the memory of autobiographical events (times, places, associated emotions, and other contextual who, what, when, where, why knowledge) that can be explicitly stated. It is the collection of past personal experiences that occurred at a particular time and place.

24 Grumpy.. Alcohol Sedative Inhibits reticular activating system (consciousness), NMDA (neuroexcitation) U-shaped dose response curve: 2-3 drinks: Anxiolytic, disinhibiting, pleasurable 8-12 drinks: Depression, anger, sedation Tolerance develops quickly

25 Alcohol Intoxication Impairs judgment, slows response time, impairs psychomotor functioning Acute risk: Accidents, violence, suicide Anger, emotional lability, impulsivity, impaired judgment, trouble reading situation

26 What about. Law enforcement testing for acute intoxication?

27 CAGE Questions: Have you ever felt you needed to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about drinking? Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

28 Alcohol RED FLAGS (an incomplete list) Pancreatitis/ Esophageal varicies / Cirrhosis Cardiomyopathy Peripheral Neuropathy Dementia Wernicke / Korsakoff Sydnrome Dupuytren s contractures

29 Medications to reduce drinking Naltrexone Competitive opioid antagonist: blocks alcohol-induced endorphin release, affects dopamine Decreases cravings, and relapse rates The Sinclair Method Pharmacologic Extinction Take Naltrexone 1-2 hours before drinking +/- psychotherapy

30 Medications to reduce drinking Acamprosate Enhances GABA system to relieve subacute withdrawal symptoms Not to be given until after acute alcohol WD (~5 days)

31 Medications to reduce drinking Disulfiram Aversion therapy Topamax Baclofen Gabapentin

32 Happy... Ecstasy Stimulant with mild hallucinogenic properties Methylenedioxymethamphetamine (MDMA) Medical use: Used in psychotherapy sessions in California in 1970 s Euphoria / openness / empathy Most common use now is by youth at rave parties

33 New for MDMA Studies in PTSD, etc Everything old is new again

34 Ecstasy toxicity brain damage loss of axons and >80% depletions in serotonin levels Long term effects have yet to be determined Deaths from Hyperthermia

35 Bashful. Lets look at an association between Depression and substance use. Hx of Depression or other Mental Health disorder: 3-4X more likely. (Braden 2009, Edlund, 2010) Patients with Substance Abuse or Mental Health disorder are more likely to receive: Higher opioid doses and higher potency opioids Concurrent sedative-hypnotic medications (Saunders 2012)

36 Doc... Prescription Opioids Due to ease of availability, ALL health care workers have an increased vulnerability Anaesthesiologists may be particularly prone to Fentanyl

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38 Sneezy... Cocaine Medical uses: topical anaesthetic, vasoconstrictor, stimulant Action: Blocks presynaptic uptake of dopamine, norepinephrine, epinephrine Route: Nasal, smoke (crack), injection Rapid entry into CNS (especially crack ) Most reinforcing of all drugs

39 Cocaine (cont.) Intoxication: Euphoria, paranoia, hallucinations Lasts 20 minutes With repeated use, euphoria lasts a few seconds, followed by paranoia

40 Cocaine and Dr. Sigmund Freud letters to his brother 1884: "If all goes well, I will write an essay on it and I expect it will win its place in therapeutics by the side of morphine and superior to it.... I take very small doses of it regularly against depression and against indigestion and with the most brilliant of success. 1896: I need a lot of cocaine... 40

41 Snow White Who else do you think was supplying Sneezy with his cocaine?

42 Females and Substance abuse Now initiate their use of substances at an earlier age than previous generations From Substance abuse and dependence increased in women (5.7%6.8%) & decreased in men (12.5%11.5%) Among youth aged 12-17, rate of substance abuse and dependence LOWER in males than females (7% vs 8.2%) SAMSA 2009, results from national survey on drug use and health 42

43 Females : Telescoping Women who drink progress more rapidly to serious alcohol related physical and social consequences than males Shorter time between landmarks of illness progression Piazza et al, 1989; Randall et al,

44 Females : Telescoping This happens at lower doses of alcohol consumed less frequently Similar findings for accelerated course with other substances Piazza et al, 1989; Randall et al,

45 Final thoughts: All substances that can be misused, usually start with qualities that have some benefits However, these qualities can lead to harm in certain vulnerable members of our population.

46 Thank