Addiction Overview. Diane A. Rothon MD. Causes Consequences Treatments. Methadone/Buprenorphine 101 April 1, 2017
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1 Addiction Overview Causes Consequences Treatments Methadone/Buprenorphine 101 April 1, 2017 Diane A. Rothon MD
2 Why? would you listen to this presentation Review the definition and neurobiology of addiction Learn about the risks, costs and burden of substance use See how different drugs affect the brain Understand how opioid agonist treatment works Review effective interventions and increase your interest TERMINOLOGY CURIOSITY INTEREST
3 DEFINITIONS Dependence vs. Addiction A physiological response marked by cravings, increasing tolerance and use, and withdrawal symptoms when use is discontinued. Includes dependence + social, behavioural and emotional aspects.
4 Prevalence of Addiction 20% of primary care visits 40% of hospitalized patients 60% of trauma admissions 50% of patients with Axis I
5 Addiction as a Chronic Illness Chronic Disease in BC Hypertension 836 Addiction 400 Hypertension Diabetes Cancer Addiction Diabetes Cancer Asthma 114 Asthma Congestive Heart Failure Congestive Heart Failure Thousands of British Columbians Stepping Forward Improving Addiction Care in BC March 2009
6 Alcohol and Drug Use Crossing the Line Zero Use Low Risk Use Risky Use Dependent Use 20 25% 50 60% 15 20% 5 10% Early Mid Late-stage % of Population
7 Cost of Addiction (Canada 2002) Legal substances: 80% of the total cost Tobacco: $17 billion (43%) Alcohol: $14.6 billion (37%) Illegal drugs account for $8.2 billion: 20%
8 Alcohol The Most Harmful Drug Drug harms in the UK: A multicriteria decision analysis The Lancet Volume 376, Issue 9752, Pages , 6 November 2010 Assessed 20 substances most commonly used in the UK for their potential to cause 16 harms CONCLUSION: Alcohol more harmful than heroin, crack
9 Screening Tools C.A.G.E. Have you felt the need to Cut down Have people Annoyed you by commenting Have you ever felt Guilty about using Have you ever needed an Eye opener
10 The 5 Cs of Addiction Compulsive use (First thought AM, last thought PM) Use as a Coping strategy Loss of Control (1 is too many, 100 not enough) Craving (Preoccupation, triggers, associations) Life-damaging Consequences (Family, work, health) REMINDER: The primary drivers in addiction are REWARD and RELIEF
11 Substance Use Disorder: DSM-V New DSM-V has 11 (up from seven) criteria Addiction severity specifiers: Mild: 2-3 criteria Moderate: 4-5 criteria Severe: 6 or more criteria positive
12 Medical Risk Factors
13 Addiction Risk Factors Genetics (What we are born with) Stressors (Especially in childhood) Environment (What we experience) Early brain exposure to drugs (Decreases dopamine tone)
14 Relative Contribution of Risk Factors Environment/Stressors/Early use Genetics Substance Drugs don t cause addiction
15 Factors Influencing Substance Use Availability Societal attitude Peer pressure Price Marketing REMINDER: The primary drivers in addiction are REWARD and RELIEF
16 Remember: The primary drivers in addiction are REWARD
17 and RELIEF
18
19 BRAIN CHEMISTRY ADDICTION IS A BRAIN DISORDER
20
21 Dopamine Release The reward centre goes Squirt Rothon 2017
22
23 OCTOPAMINE
24 Survival of the Species Neurochemicals such as octopamine and dopamine ensure the survival of the species They drive eating, rearing/nurturing behaviours, safety/shelter seeking, and procreation Addiction highjacks and replaces these primary drive states
25 The Perfect Storm Inherited + Stressors + Early Brain Exposure + Environmental Learning Repeated drug use New primary drive states develop
26 includes all (non-chemical) Behavioural Addictions: Gambling Shopping *VERY hard to treat Porn Exercise Food* Sex Internet Work Risk-taking
27 Drugs just happen to be faster
28 Physical Evidence Dopamine Reward System Reward Centre (reward, pleasure, comfort) Anxiety Centre (alarm, arousal, anxiety)
29 Neurons talk to each other
30 Dopamine Tone = Dopamine concentration + Receptor density Release Recycle Activate From: NIDA 2008
31 DYSREGULATION
32
33 Signs of Stimulant Intoxication Dilated pupils Agitation/Restlessness Anger/Irritability Pressured speech Paranoia Delusions
34
35 Signs of Opioid Intoxication Pinpoint pupils Drowsiness/Lethargy Nodding off Falling asleep Slurred speech
36 CB1 Receptor Sites
37 THC and the Brain Normal: Naturally occurring (endogenous) cannabinoids bind CB1 and CB2 receptors in the brain Play a vital role in the maturation of brain networks in adolescence including: Brain cell growth, motor activity, appetite, motivation, mood, immune system, reward, learning and memory Abnormal: THC floods CB1 receptors causing neurotoxic changes that alter brain function, maturation, brain volume, and IQ
38 THC Profoundly Impacts Motivation Motor coordination and reflexes Performance and intelligence Mental health Not only during use but long-term Reference: -The Effects of Cannabis Use during Adolescence
39 TREATMENT
40 DETOX IS NOT ADDICTION TREATMENT it s just detox
41 12-Step Programs: AA NA OA GA EFFECTIVE: Both as adjuncts and on their own STEPS 5 & 9: Recovery essentials - Reduce shame INCREASES DOPAMINE RECEPTORS DENSITY
42 C A R I N G
43 CARING as TREATMENT G.A.D.
44 Effects on Abstinence Rates of Brief Contact vs Medication Abstinence rate (%) Stopped Contact Medication + Contact Medication only 0 Baseline 24 Weeks 52 weeks McLellan et al, JAMA, 1993; Kraft et al, American Journal of Psychiatry, 1997
45
46 Opioid vs. Opiate Opiate - narcotic analgesic derived directly from the opium poppy (natural) Morphine, codeine, thebaine Opioid - narcotic analgesic that is at least part synthetic, not found in nature Heroin, oxycodone, hydromorphone
47 Why the Focus on Opioids?
48 Effective Treatments: Opioid Agonist Treatment (OAT) Methadone and Suboxone
49 Methadone is a long-acting synthetic opioid agonist the patient can take by mouth
50 Methadone 24-Hour Dose Response Dose Response Heroin Normal range Subjective w/d 0 hrs. Time Objective w/d 24 hrs. Slide courtesy of Dr. J. Thomas Payte
51 BASIC GOALS of MMT Prevention of withdrawal symptoms for 24 hours or more Elimination of drug cravings Blockade of euphoric effects of illicit self-administered opioids Restoration of normal function and benefit from counselling 51
52 OPIOID Agonists and Antagonists Work Like This:
53 Opioid Blockade: Methadone (Methadose) naltrexone Antagonists naloxone heroin methadone Opioid Receptor Agonists
54 LONG-TERM GOALS Measurable Benefits of Treatment Work Sleep Sexuality Nutrition Health Exercise Spirituality Friendship Hobbies + Safe housing, decreased criminality, counselling, self-esteem, etc. Adapted from: G. McFadden, 1998
55 to saturate receptors
56 As long as patient wants and benefits from continued treatment Rothon 2012
57 When is it OK to STOP M/SMP? Without alternate solutions in place first: Almost 100% return to illicit opioid use
58 Patients change when they Perceive they have a problem Feel they can make a change Are active participants in setting goals
59 Best Practice Tip: Most effective approach is to talk about what is on the person s mind
60 Physicians are effective when... We think about addictive disorders in the category of medical disorders that require life-long treatment Our goal is not necessarily to eliminate use but to increase the length of time between substance use events
61 Mental Health Factors
62 The Iceberg Metaphor
63 Diagnostic Approach } What s wrong with you?
64 Trauma-Informed Approach What s wrong with you? What happened to you?
65 Challenging Lives Summary Addiction Medicine practitioners encounter thousands of challenging lives every day To help make a difference we must: Always look below the surface Understand what drives addiction Explore the causes of mental illness Discard negative preconceptions Ask what happened rather than what s wrong
66 Websites ASAM Weekly - sign up at asam.org NIDA News - sign up at drugabuse.gov College methadone and pain literature cpsbc.ca BC Centre on Substance Use website bccsu.ca
67 67
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