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1 Chemical Dependency Relapse Pathways Relapse Prevention Medications Understanding the how, why, where and when.
2 Acknowledgements La Hacienda Treatment Center American Society of Addiction Medicine National Institute on Drug Abuse
3 Definition of Dependency A primary, progressive biochemical, psychosocial, py,g genetically transmitted chronic disease of relapse who s hallmarks are denial, loss of control and unmanageability.
4
5 Natural Rewards Elevate Dopamine Output of Basal DA O % o Empty FOOD Box Feeding NAc shell Time (min) Source: Di Chiara et al. Levels ine) on (% Baseli Concentratio DA C Sample Number ScrScr BasFemale 1 Present SEX Scr Mounts Intromissions Ejaculations Scr Female 2 Present Source: Fiorino and Phillips Copulation F Frequency
6 l Release % of Basal Effects of Drugs on Dopamine Levels Accumbens AMPHETAMINE DA DOPAC HVA hr Time After Amphetamine % of Basal Release Accumbens COCAINE DA DOPAC HVA hr Time After Cocaine al Release % of Basa NICOTINE Accumbens Caudate Release % of Basal 200 Release Accumbens MORPHINE Dose (mg/kg) hr Time After Nicotine hr Time After Morphine Source: Di Chiara and Imperato
7 Dopamine Transporters in Methamphetamine Abusers 2.4 Normal Control Dop pamine Tr ransporte ers (Bmax x/kd) Normal Controls Meth Abusers Methamphetamine Abuser p < Methamphetamine abusers have significant reductions in dopamine transporters. BNL - UCLA - SUNY NIDA - ONDCP - DOE
8 Dopamine Transporters in Methamphetamine Abusers Dopa amine Tran nsporter Bmax/Kd Time Gait (seconds) Delayed Recall (words remembered) Motor Task Loss of dopamine transporters in the meth abusers may result in slowing of motor reactions. Memory Task Loss of dopamine transporters in the meth abusers may result in memory impairment. BNL/UCLA/SUNY NIDA, ONDCP, DOE
9 Dopamine D2 Receptors in Addiction Cocaine Control groups Experimental groups Meth Alcohol l Food
10
11 Addictions Hypothalamic Dysregulation Impacts other areas of the brain including the Prefrontal Cortex, Cingulate and Pre- cingulate Gyrus, the Hippocampus, and the Amygdala.
12
13 Challenge: Normal Drug Use Addiction Treatment
14 Three Major Relapse Pathways I. Cross Addicting Drugs II. People/Place/Things III. BHALT B.H.A.L.T.
15 Cross Addicting Drugs a. Chemical of choice b. Related drugs c. Tobacco d. Life long relapse pathway
16 l Release % of Basal Effects of Drugs on Dopamine Levels Accumbens AMPHETAMINE DA DOPAC HVA hr Time After Amphetamine % of Basal Release Accumbens COCAINE DA DOPAC HVA hr Time After Cocaine al Release % of Basa NICOTINE Accumbens Caudate Release % of Basal 200 Release Accumbens MORPHINE Dose (mg/kg) hr Time After Nicotine hr Time After Morphine Source: Di Chiara and Imperato
17 Cross Addicting Drugs a. Chemical of choice b. Related drugs c. Tobacco d. Life long relapse pathway
18 Chemicals of Choice Cannot be a social or recreational user Cannot use in a different form or method Cannot use just on special occasions Cannot use PERIOD
19 CossAddicting Cross-Addicting Chemicals Impact on the hypothalamus as the drug of choice Usually leads back to the drug of original dependency Life long relapse pathway
20 Pain Control ol in Addiction Opiates are high risk in addictions Non Steroidal Anti-inflammatories inflammatories are safe Some skeletal muscle relaxers are safe Physical therapy, stretching, t exercise and massages are helpful Having a target for pain control or reduction
21 Anxiety in Addictions Benzodiazepines are rarely safe to use SSRI s can be used for Anxiety Disorders Other Anti-Depressant Classes can also be helpful in Anxiety Disorders Meditation and Relaxation Techniques EXERCISE
22 Sleep in Addictions Do not recommend hypnotic agents Go to bed at the same time every night No caffeine within 6 hours of bedtime No meals within 3 hours of bedtime No exercise within 3 hours of bedtime Use the bed only for sleep.
23 Tobacco 23% of Americans are addicted to tobacco >90% of the addicted population use tobacco Tobacco Cessation MUST be encouraged Relapse rates vary from 2 times to 5 times greater in addicts who continue to use tobacco
24 People/Place/Things a. History of discovery b. Three month limit for relapse
25
26
27 BHALT B.H.A.L.T. All appear to be stress mediated Relation to the Amygdala, the H-P-A AAxis Axis, and the release of CRF Reduces with time as well
28
29 BHALT B.H.A.L.T. a. Boredom b. Hunger c. Anger/emotions d. Loneliness e. Tiredness
30 Relapse Prevention ention Medications I. Antabuse II. III. IV. Campral ReVia Vivitrol V. Off label
31 Antabuse a. Mechanism of action b. Dosing c. Side Effects d. Efficacy
32 Campral al a. Mechanism of action b. Dosing c. Side Effects d. Efficacy
33 ReVia a. Mechanism of action b. Dosing c. Side Effects d. Efficacy
34 Vivitrol it a. Mechanism of action b. Dosing c. Side Effects d. Efficacy
35 Off label
36 Dual Diagnosis 1. Prevalence 2. Testing 3. Treatment
37 Spiritual Component of Recovery
38 Dr. Daniel Boone La Hacienda Treatment Center d
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