INTENSIVE UPDATE AUGUST 24 - 26, 2018 & BOARD REVIEW Loews Chicago O’Hare Hotel Rosemont, IL INNOVATIVE • COMPREHENSIVE • HANDS-ON Addiction Medicine - Substances of Abuse Bradley J. Miller, DO, FAAFP The American College of Osteopathic Family Physicians is accredited by the American Osteopathic Association Council to sponsor continuing medical education for osteopathic physicians. The American College of Osteopathic Family Physicians designates the lectures and workshops for Category 1-A credits on an hour-for-hour basis, pending approval by the AOA CCME, ACOFP is not responsible for the content. Substances of Abuse ACOFP Intensive Update and Board Review in Osteopathic Family Medicine Bradley J. Miller, DO, FAAFP Williamsport Family Medicine Residency Objectives • Define Addiction • Review current statistics and disease burden of substance abuse in the United States. • Review DSM V criteria for substance use disorders • Review specific substances of abuse (opioids, alcohol, nicotine, MJ) and accepted behavioral and pharmacologic treatments 1 What Is Addiction: ASAM Definition1 Short Definition of Addiction Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.” 1. American Society of Addiction Medicine. http://www.asam.org/docs/publicy-policy- statements/1definition_of_addiction_long_4-11.pdf?sfvrsn=2; accessed April 13, 2012 What is addiction? Characteristics of Chronic Disease • Chronic, ie no known cure; must be managed over time – long-lasting chemical changes in the brain regardless of detoxification • Relapsing – with and without treatment, craving and compulsive, pathological pursuit of substance can return • Progressive – gets worse over time; high fatality rates for addiction specifically 2 The evolution of dopamine reward… • The midbrain of the human is almost identical to that of an amphibian. – All animals have the same basic reward wiring. – Behaviors that are rewarding: • Warm Body • Eating Full Belly • Reproductive activity – The brain provides a reward of “well being” to reinforce these behaviors that are positively associated with SURVIVAL. • 2. Physiologic Range of reward is on a scale of 1-50. Food Sex • 3. Supra-physiologic range of reward with drugs and alcohol. – Range of 50-10,000. – DEEP IMPRINT for Reward behaviors = Difficult to forget Courtesy Dr. Darryl Inaba Pharm.D. CADC III 3 What is addiction? *National Institute of Drug Abuse: https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain National Trends Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/ data/ 4 DSM-V Substance Related Disorders – Nomenclature helps define SUD as a continuum and removes confusion regarding dependence with “addiction” – Disorder, Severity (based on # of specific criteria for substance), Category – Matches ICD-10 approaches to categorization “Alcohol Use Disorder, severe, in withdrawal” “Opioid Use Disorder, moderate, intoxication” “Gambling Use Disorder, severe, unspecified” Question An intoxicated patient is brought to the emergency department. Ocular examination reveals mydriasis. This patient was most likely using which of the following substances? (A) alcohol (B) cocaine (C) opioids (D) PCP (E) sedatives 5 Opioids Types of Opiates/Opioids • Natural opiates: • Synthetics • Morphine • Oxycodone • Methadone • Codeine • Fentanyl • Opium • Buprenorphine (partial • Semi-synthetics agonist) • Heroin • LAAM • Hydromorphone • Propoxyphene • Hydrocodone • Pentazocine • Butorphanol (agonist/antagonist) • Fentanyl • Dextromethorphan (agonist/antagonist) • Naloxone (pure opiate antagonist) • Naltrexone (pure opiate antagonist) 6 Common scenario • Acute pain prescription for opioid Addiction – Post-surgery – Accident – Sports injury – Medical condition • One of the major causes of opioid addiction is the use of legitimately prescribed opioid medications 13 Chronic, Non-Malignant Pain Summary (CNMP) • Use of opioids for too long greatly increases risk of: – Acute pain becoming chronic, non-malignant pain (CNMP) – Hyperalgesia (greater sensitivity to pain) – Hyperkatifeia (dysphoria; chronic negative emotional states) – Addiction 7 Common scenario • Risk is higher for: – Family history of SUD (genetics) – Individual history of SUD – Depression/Anxiety/Other MH disorders – PTSD – Childhood trauma/chronic problematic environment – Adolescents 15 National Trends Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/ data/ 8 National Trends Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/ data/ National Trends Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2011-2012 Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013 9 Drugs Involved in U.S. Overdose Deaths* - Among the more than 64,000 drug overdose deaths estimated in 2016, the sharpest increase occurred among deaths related to fentanyl and fentanyl analogs (synthetic opioids) with over 20,000 overdose deaths. Source: CDC WONDER Why are opioid medications used to treat opioid addictions? • Long-term (permanent?) changes to opioid receptor system. • Changed receptors may require an opioid to function normally. • Opioid treatment medications reduce symptoms; promote remission. • Long-term (at least 2 years, for some, lifelong) medication treatment works best. 10 Why are opioid medications used to treat opioid addictions? • Research has consistently and repeatedly found that opioid medication-assisted treatment, compared to no treatment or abstinence: – Reduces drug use – Reduces overdose and mortality – Reduces crime – Reduces costs to society – Improves functioning and quality of life • In a high percentage of cases, when medication stops, symptoms return, and overdoses and fatalities can increase, even with ongoing behavioral intervention Opiate Addiction Pharmacologic Interventions • Opiate Agonists – Methadone • Partial Agonist, Partial agonist/antagonist – buprenorphine – buprenorphine/naloxone • Antagonist – Naltrexone (Vivtrol®) 11 Medication Treatments for Opioid Use Disorder Conceptual Representation of Opioid Effect Versus Log Dose for Opioid Full Agonists, Partial Agonists, and Antagonists Full Agonist: (high intrinsic activity) (Oxycodone, Heroin, Methadone) Potentially Lethal Dose Partial Agonist: (low intrinsic Opioid EffectOpioid activity) (Buprenorphine) Antagonist: (no intrinsic activity) Log Dose (Naloxone/Naltrexone) Nutt&Langford, 2008, Brit Jl Pharm Methadone • Full opiate agonist • Tightly blocks two subset opioid receptor • Well studied for decades • Safe in pregnancy • Must be administered at a federally licensed treatment facility • Abuse potential • Very long half life • CAUTION: can cause QT prolongation 12 Naltrexone (Vivitrol®) • Naltrexone is a opiate antagonist • Tightly blocks mu opioid receptors • FDA approved for treating alcohol dependence and opiate dependence – Decreases cravings in patients who abuse alcohol • Comes in oral and IM depot formulations – oral used to trial naltrexone prior to committing to IM – IM- (Vivitrol®) – depot formulation that is given monthly. If patients use opiates while on, no high. • CAUTION: Will cause opiate withdrawal • BLACK BOX WARNING-acute hepatic toxicity Buprenophine • Partial agonist/antagonist of the mu opioid receptor – Binds to and activates the receptor – Decreases cravings – Null overdose potential (w BZDs) – Partial agonists have a “ceiling effect:” • larger doses do not produce greater highs-- has a very low risk of abuse and overdose. 13 Question Which of the following has an amount of alcohol consistent with a “standard drink”? A. One Long Island Iced Tea B. 1 shot (1.5 ounces) of whiskey C. One 16 ounce beer D. One martini (3 ounces of vodka) E. There is no standard drink definition, every alcoholic beverage is a standard drink Alcohol Use Disorder 14 National Trends - ETOH Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/ data/ USPSTF • Alcohol Misuse, Screening and Behavioral Counseling Interventions in Primary Care – Adults – The USPSTF recommends that clinicians screen adults aged 1 years or older for ETOH misuse and provide persons