Module II: Overview of Substance Use Disorders Section A: Overview of Addiction

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Module IIOverview of Substance Use Disorders
Section A Overview of Addiction
Project MAINSTREAM
November 2005
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Learning Objectives

• Health Care Professionals will be able to
• Define substance abuse and dependence
• Discuss epidemiology of substance use disorders
• Cite theories of addiction
• Discuss the neurobiology involved in addiction

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DSM-IV Criteria Substance Abuse

• A maladaptive pattern leading to significant
  distress or impairment with one or more of the
  following in a 12-month period
• Recurrent failure to fulfill major obligations
• Recurrent physically hazardous behavior
• Recurrent substance-related legal problems
• Continued use despite social problems
• Symptoms have never met dependence criteria

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DSM-IV Criteria Substance Dependence

• Three or more of the following at the same time
  in a 12-month period
• Tolerance
• Withdrawal
• More ingested than intended
• Desire or unsuccessful attempts to reduce use
• Much time involved with substances
• Reduced time spent on other important activities
• Continued use despite physical or psychological
  problems

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Substance Dependence Course Specifiers

• With or without physiological dependence
• Early full or partial remission
• Sustained full or partial remission
• On agonist therapy
• In a controlled environment

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Other Definitions of Addiction

• American Society of Addiction Medicine defines
  alcoholism as
• A primary, chronic disease with genetic,
  psychosocial, and environmental factors
  influencing its development and manifestations.
  The disease is often progressive and fatal. It is
  characterized by continuous or periodic impaired
  control over drinking, preoccupation with the
  drug alcohol, use of alcohol despite adverse
  consequences, and distortions in thinking, most
  notably denial.

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Substance Dependence or Abuse among Persons Aged
12 or Older 2003 National Survey on Drug Use
and Health
Numbers in Millions
21.6
3.1
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Prevalence of Alcohol Use
NIAAA National Epidemiologic Survey onAlcohol
and Related Conditions (NESARC)
Any Alcohol Disorder 17.6 million (8.5)
Alcohol Dependence 7.9 million (3.8)
Alcohol Abuse 9.7 million (4.7)
NIAAA National Institute on Alcohol Abuse and
Alcoholism (Grant BF, et al. Arch Gen
Psychiatry. 200461807-816).
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Use of Selected Illicit Drugs among Persons Aged
12 or Older 2002 and 2003
Percent Using in Past Month
Any Drug
Psycho-therapeutics
Hallucinogens
Marijuana
Cocaine
Inhalants
(Data from the National Survey on Drug Use and
Health)
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Dependence or Abuse of Specific Illicit Drugs
among Persons Aged 12 or Older 2003
Numbers (in Thousands) of Users with Dependence
or Abuse
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Illicit Drug Use, by Age 2003
Percent Using in Past Month
12-13
14-15
16-17
18-20
21-25
26-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
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Age in Years
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Tobacco Use among Persons Aged 12 or Older 2002
and 2003
Percent Using in Past Month
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Tobacco Use among Youths Aged 12 to 17 2002 and
2003
Percent Using in Past Month
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Need for and Receipt of Specialty Treatment for
Alcohol or Illicit Drugs among Persons Aged 12
or Older 2002 and 2003
Numbers in Millions Needing Treatment in Past Year
22.8
22.2
?
?, ? Significant change 2002 to 2003
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Reasons for Not Receiving Substance Use Treatment
among Persons Aged 12 or Older Who Needed But Did
Not Receive Treatment and Felt They Needed
Treatment 2003
Percent Reporting Reason
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Substance Dependence or Abuse among Adults Aged
18 or Older, by SMI 2003
Percent Dependent or Abusing in Past Year
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Co-Occurrence of SMI and Substance Use Disorders
among Adults Aged 18 or Older 2003
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Past Year Treatment among Adults Aged 18 or Older
with Co-Occurring SMI and a Substance Use
Disorder 2003
Treatment Only for Mental Health Problems
Treatment for Both Mental Health and Substance
Use Problems
39.8
7.5
3.7
Substance Use Treatment Only
No Treatment
49.0
4.2 Million Adults with Co-Occurring SMI and
Substance Use Disorder
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Societal Costs of Alcohol Abuse
Total Cost 184.6 Billion
7,466 (4)
24,093 (13)
15,963 (9)
10,085 (5)
2,909 (2)
1,253 (1)
36,499 (20)
86,368 (47)
Cost in millions of US dollars FAS fetal
alcohol syndrome.
(Harwood, 2000.)
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Substance Abuse and Crime

• One-third of all criminal justice costs relate to
  alcohol, drug abuse, or mental illness
• One-half of individuals in prison for violent
  crime report being intoxicated at the time of the
  offense

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Stigma and Addictions

• Moral weakness/character flaw
• Treatment doesnt work

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DISEASE Model of Addictions

• Pathologic condition with clearly measurable,
  characteristic physiology/neurobiology
• Genetic predisposition/environmental precipitants

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Addictions as a Chronic Illness

• Diabetes/Hypertension
• Genetic predisposition/environmental precipitants
• Medication non-compliance/failure to make
  recommended behavioral change primary reason for
  treatment failure
• 40-60 relapse every year

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Genetic Factors Associated With Alcohol
Dependence

• 3 to 4 times higher risk in close relatives of
  people with alcohol dependence. Higher risk
  associated with
• Greater number of affected relatives
• Closer genetic relationships
• Severity of alcohol-related problems inaffected
  relative(s)
• Significantly higher risk in monozygotic twin
  than dizygotic twin of a person with alcohol
  dependence
• 3- to 4-fold increase in risk in adopted children
  with a natural parent who is alcohol dependent
  despite being raised by adoptive parents without
  the disorder

(American Psychiatric Association, 2000.)
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Neurobiology of Addictions

• Excellent animal models
• Multiple neurotransmitter systems
• Dopaminergic
• Serotonergic
• Opiate
• Excitatory amino acid systems
• HPA axis - stress relapse models

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Brain Reward Pathways

• The VTA-nucleus accumbens pathway is activated by
  all drugs of dependence including alcohol
• This pathway is important not only in drug
  dependence, but also in essential physiological
  behaviors such as eating, drinking, sleeping, and
  sex

(Messing RO. In Harrisons Principles of
Internal Medicine, 20012557-2561)
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Section BOverview of Addiction Treatment
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Learning Objectives

• Health Care Professionals will be able to
• Identify the broad, overarching aims of substance
  abuse treatment
• Discuss indicators for treatment and referral to
  treatment
• Describe assessment
• Discuss evaluation of treatment outcome

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Goals of Treatment

• Engage, motivate, and retain the patient in
  treatment
• Provide education about addiction
• Reduce intensity and frequency of substance use
• Prevent relapse to substance use
• Improve areas of life affected by addiction
  (e.g., employment, interpersonal relationships)
• Improve the patients quality of life

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When is Treatment Indicated?

• When the substance use interferes significantly
  with a persons social, occupational, legal, or
  physical health functioning
• When substance use causes a person clinically
  significant distress
• Psychotherapy and/or pharmacotherapy should be
  considered for all individuals seeking help with
  addiction

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Patient Assessment

• Demographics age, gender, race, marital or
  relationship status, education, religion
• Presenting problem
• Psychiatric history
• Medical history and current medications
• Legal history
• Occupational history
• Social history

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Patient Assessment (continued)

• History of substance use First use, last use,
  age of heaviest use, current frequency and
  intensity of use (e.g., amount use per week,
  number of days use per week)
• History of previous treatments for substance use
  where, for how long, inpatient vs. outpatient,
  diagnoses given, outcome of treatment
• Family history of addiction
• Social support for recovery
• Addiction status of spouse or significant other
• Suicidal or homicidal ideation

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Evaluating Treatment Outcome

• Abstinence should not be the only measure
• Harm or Symptom Reduction in
• Substance Use
• Physical health
• Occupational functioning
• Interpersonal functioning
• Legal problems, public health and safety
• Overall Quality of Life
• Improvement in comorbid psychiatric disorders
• Patient satisfaction and quality of life

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Methods of Evaluation

• Use multiple methods
• Self-report forms (e.g., surveys, questionnaires)
• Collateral reports (e.g., spouse, family,
  physicians, probation officers)
• Urine drug screen tests
• Breathalyzers
• Physical health exam
• Laboratory tests (e.g., liver function tests)

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Methods of Evaluation (continued)

• Biologic methods of evaluation can be invaluable
  for this population
• Can use to confirm patients self report,
  demonstrate improvement, and to motivate the
  patient to stay clean
• Substance abuse/dependence disorders are the only
  psychiatric disorders for which we have easy,
  measurable biologic outcomes available

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Section CTreatment Modalities
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Learning Objectives

• Health Care Professionals will
• Describe consideration for treatment
• Identify the importance of the therapeutic
  alliance
• Discuss the major models of addiction
  psychotherapy and pharmacotherapy

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Treatment Modalities

• PSYCHOTHERAPY AND SELF-HELP APPROACHES
• Individual Psychotherapy
• Group Psychotherapy
• Cognitive Behavioral Therapy
• Alcoholics Anonymous and Twelve-Step Groups
• Motivational Enhancement Therapy and Motivational
  Interviewing
• Family Therapy
• Psychodynamic Therapy
• Pharmacotherapy

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Therapeutic Alliance

• The therapist-patient relationship is a critical
  component of all treatment modalities
• Work to establish a positive alliance at the
  beginning of treatment
• Promote a positive therapeutic alliance
• Minimize or avoid negative reactions
• Avoid confrontation
• Convey a high degree of empathy, confidence, and
  hope

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When is Treatment Indicated?

• When the substance use interferes significantly
  with a persons social, occupational, legal, or
  physical health functioning
• When substance use causes a person clinically
  significant distress
• Psychotherapy and/or pharmacotherapy should be
  considered for all individuals seeking help with
  addiction

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Individual Therapy
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Individual Therapy

• Can be conducted in any treatment setting
  inpatient, outpatient, intensive day treatment,
  criminal justice institutions
• Advantages
• Privacy
• Individualized pace
• More one-on-one time with the clinician
• Logistically easier
• Can be tailored for patients other comorbid
  conditions
• Can help prepare a patient for group therapy

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Individual Therapy (continued)

• Frequency or dose depends on a number of factors
  level of symptom severity, type of substance,
  resources, motivation, social support
• Typically, therapy is more intensive (e.g., 1-2
  sessions per week) at the beginning and then
  tapers off over time (e.g., every other week,
  then once a month for several months)

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Individual Therapy (continued)

• Approaches vary widely (e.g., cognitive-behavioral
  model, psychodynamic, counseling and case
  management issues, brief, long term)
• Common Characteristics
• Concrete, behavioral goals
• Addresses related areas of impairment
• Helps patient develop basic coping skills

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Group Therapy
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Group Therapy

• The most common form of addiction treatment
• Like individual therapy, it can be conducted in
  many treatment settings (e.g., inpatient,
  outpatient criminal justice institutions)
• Advantages
• Economic
• Presence of others helps combat social stigma
• Peer models and peer support
• Public nature of groups

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Group Therapy (continued)

• Approaches vary widely. For example
• Time limited psychoeducational groups
• Cognitive-behavioral model groups
• Relapse prevention groups
• Ongoing process oriented groups
• Family therapy groups
• Gender specific groups
• Adolescent groups

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Cognitive-Behavioral Therapy
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Cognitive-Behavioral Therapy

• Extensive empirical support
• Addresses false beliefs or high-risk cognitions
  about substance use
• Examples of high-risk cognitions
• I need a drink to relax.
• I cant get through this without a hit.
• No one will like me if Im not using.

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Cognitive-Behavioral Therapy(continued)

• Examples of high-risk behaviors
• Keeping alcohol or drugs in the house just in
  case some friends come over and want to use.
• Going out with substance using friends to prove
  that you can be around them and not drink.
• Driving by a familiar bar or neighborhood to get
  home when other routes could be taken.
• Identify triggers for use (people, places,
  emotions) and high risk situations.

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Cognitive-Behavioral Therapy(continued)

• Learn drink (or drug) refusal skills
• Use role-play in session
• Learn Problem-solving skills
• Learn to anticipate problems and develop
  effective coping strategies

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Alcoholics Anonymous (AA) and Twelve-Step Groups
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AA and Twelve-Step Groups (continued)

• Founded in 1935
• A worldwide organization with over 2.2 million
  members
• Structured around the Twelve Steps
• Peer-led
• Only requirement to join is a desire to stop
  drinking
• There are similar groups nationwide for other
  substances and issues (e.g., Cocaine Anonymous,
  Narcotics Anonymous, Overeaters Anonymous,
  Gamblers Anonymous, Nicotine Anonymous)

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AA and Twelve-Step Groups (continued)

• Advantages
• Social peer support network
• Free
• Offered in most urban and suburban areas
• Meeting held several times per day/week
• Sponsor system available 24 hours/day
• WEBSITE to find meetings and other information
  http//www.alcoholics-anonymous.org

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The Twelve Steps of AA

• The Twelve Steps 1-4
• We admitted we were powerless over alcohol Made
  a searching and fearless moral inventory of
  ourselves.
• that our lives had become unmanageable.
• Came to believe that a Power greater than
  ourselves could restore us to sanity.
• Made a decision to turn our will and our lives
  over to the care of God as we understood Him.

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The Twelve Steps of AA (continued)

• The Twelve Steps 5-8
• Admitted to God, to ourselves and to another
  human being the exact nature of our wrongs.
• Were entirely ready to have God remove all these
  defects of character.
• Humbly asked Him to remove our shortcomings.
• Made a list of all persons we had harmed and
  became willing to make amends to them all.

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The Twelve Steps of AA (continued)

• The Twelve Steps 9-12
• Made direct amends to such people wherever
  possible, except when to do so would injure them
  or others.
• Continued to take personal inventory and when we
  were wrong promptly admitted it.
• Sought through prayer and meditation to improve
  our conscious contact with God, as we understood
  Him, praying only for knowledge of His will for
  us and the power to carry that out.
• Having had a spiritual awakening as the result of
  these steps, we tried to carry this message to
  alcoholics, and to practice these principles in
  all our affairs.

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Motivational Enhancement Therapy (MET) and
Motivational Interviewing (MI)
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MET and MI (continued)

• Based on the transtheoretical model of the stages
  of change
• Helps patients move further along the continuum
  of change (e.g., from believing they have no
  problem, to considering making a change, to
  actually making changes, to maintaining those
  changes)
• Focused on internally motivated change
• Non confrontational style
• Help patients resolve ambivalence about stopping
  substance use

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Family Therapy
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Family Therapy (continued)

• Addiction often affects the entire family
• Advantages of involving family members
• Assist in accurate assessment and diagnosis.
• Increase subsequent engagement in treatment.
• Social support.
• Helps therapist understand factors that might
  contribute to the patients addiction.
• Assist in compliance with medication and keeping
  appointments.
• Help establish a substance-free family
  environment.

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Family Therapy (continued)

• Approaches to family therapy can also vary widely
  by how often family members are included (e.g.,
  several or all therapy sessions), if they
  participate in their own therapy or self-help
  program (e.g., Al-Anon groups) and the
  theoretical approach (e.g., behavioral,
  psychodynamic)
• Use nonpathologizing language and a collaborative
  stance with family members

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Psychodynamics and Addiction
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Psychodynamics and Addiction (continued

• Psychodynamic principles vs. Psychoanalysis
• Focus of modern psychodynamics
• Affective control and regulation (painful
  emotions, shame, powerlessness)
• Self-medication and escape
• Fixation and developmental delay
• Fear of intimacy and closeness

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Psychodynamics and Addiction (continued)

• Abstinence is essential
• Current conflicts and how they relate to the past
• Interpretations
• Relapse prevention
• Aims increase self-awareness, growth, work
  through conflicts.
• Can be combined with other treatment modalities

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Psychodynamics and Addiction
(continued)

• Good candidates higher socioeconomic status,
  marital stability, less severe mental illness
• Likely to seek out psychodynamic treatment
  psychological mindful, insight, desire to
  understand or find meaning in behaviors, ample
  time and funds, capacity for intimacy

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Pharmacotherapy
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Pharmacotherapy (continued)

• Applications
• Medications to treat withdrawal
• Medications which decrease desire to consume
  (decrease craving)
• Medications which block the reinforcing effects
  of drugs of abuse
• Medications which produce adverse effects in
  combination with drugs of abuse
• Medications to treat co-morbid disorders

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Pharmacotherapy (continued)

• Ideal Pharmacologic Addictions Treatment
• Low abuse potential
• Safety
• Agents that treat both disorders

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Relapse Prevention and Aftercare

• Addiction is a chronic problem
• Once abstinence is achieved, the focus turns
  to maintaining abstinence and the positive
  changes accomplished in treatment
• High-risk situations are identified, practiced,
  and prepared for in advance

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Section DPharmacotherapy Treatments
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Learning Objectives

• Health Care Professionals will
• Examine the role pharmacotherapy may play in the
  treatment of substance use disorders
• Examine an overview of the characteristics of the
  ideal pharmacologic treatments
• Discuss pharmacotherapies examined for the
  treatment of specific drugs of abuse

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Pharmacotherapy of Substance Abuse

• Medications to treat withdrawal/protracted
  abstinence syndromes
• Medications which decrease desire to consume
  (decrease craving)
• Medications which block the reinforcing effects
  of drugs of abuse
• Medications which produce adverse effects in
  combination with drugs of abuse
• Medications to treat co-morbid disorders

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Ideal Pharmacologic Treatment

• Low abuse potential
• Safety
• Agents that treat both disorders if dual diagnosis

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Pharamcotherapy for Drugs of Abuse

• Less evidence available
• Cocaine
• Marijuana
• Club drugs

• Well-studied or proven treatments
• Alcohol
• Opioids
• Nicotine

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Alcohol
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Pharmacotherapy Overview Alcohol

• Withdrawal
• Benzodiazepines/anticonvulsants
• Relapse prevention
• Disulfiram
• Naltrexone
• Acamprosate

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Alcohol Withdrawal Protocols Benzodiazepines

• Fixed dose taper
• Loading dose Oral, IV, IM
• CIWA Triggered
• Clinical PRN

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Alternative Treatments forAlcohol Withdrawal

• Compromised liver functioning
• Oxazepam (Serax)
• Lorazepam (Ativan)
• With fixed dose paradigm, taper dose, not time
  interval
• Carbamazepine
• May particularly useful in outpatients
• Phenobarbital

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Treatment of Delirium Tremens (DTs)

• Rare
• Occurs in less than 1 of patients
• Mortality rate approximately 20
• Consider alternate etiologies
• Physiologic support
• Physical restraints
• Chemical restraints
• lorazepam 2 mg haloperidol 5 mg
• intravenous every 30 minutes

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FDA-Approved Pharmacotherapies for Alcohol
Dependence

• Inhibits aldehyde dehydrogenase
• When alcohol consumed, results in nausea,
  dizziness, headache, flushing
• Decreases desire to drink
• Poor tolerability profile, low efficacy

Disulfiram (Antabuse)
Naltrexone (ReVia)

• Opioid antagonist
• Binds to opioid receptors, thus blockingalcohol
  reward pathways
• Black box warning regarding hepatotoxicity

FDA US Food and Drug Administration. Antabuse
is a registered trademark of Odyssey
Pharmaceuticals, Inc. ReVia is a registered
trademark of the DuPont Merck Pharmaceutical
Company (OConnor, 1998.)
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FDA-Approved Pharmacotherapies for Alcohol
Dependence (continued)
Acamprosate (Campral)

• Indicated for maintenance of abstinence from
  alcohol in patients abstinent at treatment
  initiation
• Renally cleared contraindicated in severe renal
  disease

FDA US Food and Drug Administration. Campral
is a registered trademark of Merck Santé
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Disulfiram in the Treatment of Alcohol Dependence
(Azrin et al., 1982)
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Naltrexone for the Treatment of Alcohol Dependence

• Decreases craving
• Increases time to first drink
• Increases time to heavy drinking
• Increases time to heavy drinking in alcoholics
  who have a first drink
• However, ineffective in some trials

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Alcohol Treatment (Pharmacologic)
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Acamprosate

• Inhibits ionotropic metabotropic glutamate
  receptors (mGluRs)
• FDA-approved for maintenance of abstinence from
  alcohol in alcoholic patients who are abstinent
  at treatment initiation

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Acamprosate Effectiveness

• Efficacy in 16/19 RCTs
• RCTs N3,338
• Six month abstinence AC 35, PL 24
• 12 month AC 33, PL 21
• Factors that did not predict success physical
  dependence, family history, age onset, anxiety
  symptoms, cravings, gender

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Non-FDA Approved Medications Under Study

• Ondansetron
• Topiramate
• Many others

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Opioids
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Pharmacotherapy Overview Opioids

• Detoxification
• Opioid detoxification
• Medication assisted detoxification
• Relapse prevention
• Naltrexone
• Maintenance
• Methadone
• LAAM
• Buprenorphine

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Detoxification

• Opioid substitution
• Methadone (Agonist)
• Non-Opioid Symptom Relief
• Clonidine
• Dicyclomine
• Cyclobenzaprine
• Naltrexone

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Ultra Rapid Opioid Detoxification

• Opioid antagonist administered under general
  anesthesia
• Expensive
• Few long-term clinical trials with no proven
  efficacy
• Potential risks high
• Deaths have occurred

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Naltrexone for Relapse Prevention

• Long-acting opioid blocker
• Limited effectiveness
• Poor compliance
• Poor treatment retention
• Depot formulation may offer promise

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Maintenance Treatment

• Methadone
• Gold standard
• LAAM
• Pulled from market in 2004 due to QTc
  prolongation
• Buprenorphine
• Newly approved
• Partial agonist

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Maintenance

• Methadone
• Synthesized during World War II as alternative to
  morphine
• t1/2 24-46 hours
• Good oral bioavailability
• Introduced in 1960s by Dole and Nyswander for the
  treatment of heroin addiction

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Outcomes of MMT

• 45-90 of patients in treatment for one year
  discontinue illicit opioid use
• MMT shown to reduce criminal activity in over 80
  of patients
• Patients three times more likely to die outside
  of MMT
• 5.4 times greater odds of contracting HIV for
  patients not in MMT

(J Health Sci Behav 29214-226, 1988)
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The Role of Buprenorphine in Opioid Treatment

• Partial Opioid Agonist
• Produces a ceiling effect at higher doses
• Has effects of typical opioid agoniststhese
  effects are dose dependent up to a limit
• Binds strongly to opiate receptor and is
  long-acting
• Safe and effective therapy for opioid maintenance
  and detoxification

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Buprenorphine/NalxoneSuboxone

• A partial mu agonist a mu antagonist in a 41
  ratio
• 20.5 mg 41 82 164 S.L.
• Mono form Subutex

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Potential Suboxone Advantages

• Returns opiate dependence treatment to primary
  care
• Schedule III agent
• Lower abuse potential
• Less dangerous in overdose (little effect on
  blood pressure and respiration)
• Naloxone limits parental use SL IM,IV 1100
  potency
• Long half life (37 hours)
• Less toxicity in overdose

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Potential Suboxone Disadvantages

• Physician requirements for prescribing
• Some red tape issues
• Can be abused
• Cost
• Availability problems
• Limits on patient number per practice (n 30)

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Cocaine
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Pharmacotherapy Overview Cocaine

• Acute intoxication/withdrawal
• Relapse prevention

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Treatment of Acute Cocaine Intoxication

• Psychosis
• Usually resolves spontaneously
• Benzodiazepines first line treatment
• Antipsychotics can be used if benzodiazepines
  alone are inadequate
• Note lowered seizure threshold with typicals

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Treatment of Acute Cocaine Intoxication

• Physiologic hyperexcitability
• Hypertension, tachycardia, hyperthermia, seizures
• Supportive treatment
• Benzodiazepines
• Seizure treatment with diazepam, phenobarbital,
  or phenytoin

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Relapse Prevention

• Many medications evaluated
• Antidepressants
• Dopaminergic agents
• Mood stabilizers
• Calcium channel blockers
• NO MEDICATION has had reproducible efficacy in
  the treatment of cocaine dependence

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Agents Evaluated for the Treatment of Cocaine
Dependence

• Dopaminergic agents
• bromocriptine
• L-dopa
• methyphenidate
• mazindol
• pergolide
• amantadine
• flupenthixol
• haloperidol
• bupropion
• selegiline
• benztropine
• ritanserin

• Antidepressants
• desipramine
• fluoxetine
• sertraline
• imipramine
• maprotiline
• phenelzine
• trazodone
• lithium

• Miscellaneous
• buprenorphine
• carbamazepine
• nimodipine
• nifedipine
• disulfiram
• clozapine
• tyrosine
• naltrexone
• gepirone
• Tryptophan
• Cocaine vaccine

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Nicotine
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The 5 As for Brief Intervention to Treat Tobacco
Dependence
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Who Should Receive Pharmacotherapy for Smoking
Cessation?

• All smokers trying to quit, except in special
  circumstances
• Use special consideration in following
  populations
• Patients with medical contraindications
• Individuals smoking less than 10 cigarettes/day
• Pregnant or breastfeeding women
• Adolescent smokers

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Medications to Target Nicotine Addiction

• Nicotine replacements
• Nicotine patch, gum, inhaler, lozenge, nasal
  spray
• Antidepressants
• Bupropion
• Nortriptyline
• Other
• Clonidine

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Clinical Practice Guidelines for First Line
Pharmacotherapies

• All 5 FDA-approved medications as of 2000
  (bupropion SR, nicotine gum, nicotine inhaler,
  nicotine nasal spray, nicotine patch) shown to be
  effective

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Factors in Choosing Pharmacotherapy

• Physician familiarity with medications
• Contraindications in specific patients
• Patient preference
• Previous patient experience with medication
• Patient characteristics
• History of depression, concerns about weight gain

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Considerations in Choosing Pharmacotherapy

• Patients concerned with weight gain
• Bupropion SR and NRTs shown to delay but not
  prevent weight gain
• Patients with history of depression
• Bupropion SR and nortiptyline effective
• Patients with history of heart disease
• Nicotine patch shown to be safe and not cause
  adverse cardiovascular effects

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Other Considerations

• Long term use (6 months or more) may be helpful
  in smokers with persistent withdrawal syndromes
• Pharmacotherapies may be combined
• Evidence that combining the nicotine patch with
  nicotine gum or NS increases long-term abstinence
  rates

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Marijuana
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Medications to Treat Marijuana Withdrawal

• Positive outcomes
• Nefazodone
• Oral THC
• Negative outcomes
• Divalproex
• Bupropion

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Other Medication Evaluations

• Fluoxetine shown to decrease marijuana use in
  depressed alcohol dependent patients
• Divalproex did not improve marijuana outcomes in
  a double-blind, placebo-controlled crossover trial

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Potential Advances

• Cannabinoid antagonists
• Rimonabant likely to be FDA-approved for smoking
  cessation and obesity
• May play role in treatment of marijuana dependence

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Club Drugs
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Commonly Abused Club Drugs

• Gamma hydroxybutyrate (GHB)
• 3,4-methylenedioxymethamphetamine (MDMA)
• Flunitrazepam (Rohypnol)

128
Treatment for Club Drugs

• Overdose treated with supportive care
• No pharmacological treatments reported for abuse
  or dependence

129
Methamphetamine
130
Background

• Derivative of amphetamine
• Powerful stimulant affects CNS
• Use increasing among teens
• Epidemic associated with manufacture from
  inexpensive over-the-counter ingredients in
  clandestine laboratories

131
Effects

• Increased energy and alertness
• Decreased appetite
• Intense rush, snorting 5 minutes ingesting 20
  minutes

132
Chronic Effects

• Tolerance
• Psychotic behavior paranoia, visual and auditory
  hallucinations, rages, aggression
• Anxiety, insomnia
• Cardiovascular problems
• Skin abcesses

133
Withdrawal Symptoms

• Depression
• Fatigue
• Aggression
• Psychotic symptoms may persist for months or years

• Anxiety
• Paranoia
• Intense craving

134
Treatment

• No pharmacological treatments
• Antidepressants may be used for depressive
  symptoms of withdrawal
• Cognitive behavioral interventions most effective
• Long-term treatment required

135
Section ESpecial Considerations
136
Issues in Adolescent Substance Abuse Treatment
137
Learning Objectives

• Health Care Professionals will
• Review trends in adolescent substance use
• Discuss risk and protective factors associated
  with adolescent substance use
• Discuss issues with assessment/diagnosis of
  adolescent substance use

138
Percent of Students Reporting Past Month Use of
Any Illicit Drug Has Decreased

17 Decline 2001 to 2004
Percent

P lt .05
(NIDA/MTF Survey)
139
Issues of Concern Percent of 12th Graders
Reporting Nonmedial Use of OxyContin and Vicodin
in the Past Year Remained High
12.0
10.5
9.6
9.3
10.0
8.0
Percent
6.0
5.0
4.5
4.0
4.0
2.0
0.0
OxyContin
Vicodin
2002
2003
2004
(NIDA/MTF Survey)
No year-to-year differences are statistically
significant.
140
Issues of Concern Percent of 8th Graders
Reporting Lifetime Use of Inhalants Increased

Percent

P lt .05
(NIDA/MTF Survey)
141
Referral Source for Adolescent Treatment
Admissions 1992 and 2002
(SAMSHA)
142
Primary Substance of Abuse among Adolescent
Treatment Admissions 2002
Does not include nicotine
143
Risk and Protective Factors Associated With
Adolescent Use of Tobacco, Alcohol, and Other
Drugs (Slide 1 of 2)
144
Risk and Protective Factors Associated With
Adolescent Use of Tobacco, Alcohol, and Other
Drugs (Slide 2 of 2)
(Kulig, 2005)
145
Assessment Issues

• 31 of regular drinkers from the community and
  treatment programs (n372) had abuse or
  dependence symptoms but did not meet criteria for
  a diagnosis
• (Pollock and Martin,
  1999)
• In a sample of 74,000 students, authors found
  that symptoms did not support distinction between
  abuse and dependence
  (Harrison et al., 1998)

146
CRAFFT Questions to Identify Adolescents With
Substance Abuse Problems
Two or more yes answers suggest that the
adolescent may have a serious problem with
substance abuse, and additional assessment is
warranted.
(Knight, 1999 Kulig, 2005)
147
Dual Diagnosis
148
Learning Objectives

• Health Care Professionals will
• Identify the most common co-occurring psychiatric
  diagnosis among substance abusers
• Describe issues related to the temporal
  development of dual disorders
• Consider and approach diagnostic difficulties and
  treatment

149
Comorbidity

• Comorbid psychiatric disorders are very common
  among individuals with substance use disorders
  (SUDs)
• Estimated 45 - 86 of individuals with a
  lifetime alcohol or drug use disorder meet
  criteria for at least one other mental health
  disorder
  
  (Kessler et al., 1994 Reiger et al., 1990)
• Internalizing vs. Externalizing Dual Disorders

150
Comorbid Psychiatric Disorders Among Individuals
with SUDs

• Among individuals with alcohol use disorders,
  about 22 will also have a drug use disorder
• Among individuals with a drug use disorder,
  almost half (47) will have an alcohol use
  disorder
• Affective disorders are very common. Up to 67 of
  alcohol-dependent patients, 53 of
  cocaine-dependent patients, and 75 of
  opiate-dependent patients have comorbid affective
  disorders
• Approximately 25-50 of alcohol dependent
  individuals meet criteria for an anxiety disorder
• Approximately 30-60 of patients with an SUD have
  comorbid Antisocial Personality Disorder

151
Comorbid SUDs among Individuals with Psychiatric
Disorders

• Among schizophrenia patients 50 have alcohol or
  drug dependence, over 70 have nicotine
  dependence
• Among persons with an affective disorder 32
  have a comorbid SUD. Over half (56.1) of
  patients with bipolar disorder have an SUD
• Among persons with an anxiety disorder 36 have
  a comorbid SUD
• Among persons with Antisocial Personality
  Disorder, the majority (84) have an SUD

152
(No Transcript)
153
Order of Onset

• Mental disorders typically emerge before comorbid
  substance use disorders
• This pattern is somewhat stronger for women than
  men
• Data from a large epidemiologic study found that
  the median age of onset of mental disorders was
  11 yrs old as compared to 21 yrs old for
  substance disorder

154
(No Transcript)
155
Diagnostic Difficulties

• Substance intoxication and withdrawal can mimic
  nearly any psychiatric disorder
• Stimulants/hallucinogens/cannabinoids mania and
  schizophrenia
• Alcohol/opiate/sedative-hypnotic withdrawal
  depressive and anxiety disorder

156
Diagnostic Difficulties (continued)

• Assess which disorder developed first
• Query about symptoms during periods of
  abstinence. Minimum acceptable period of
  abstinence necessary for diagnostic clarity will
  differ by diagnosis
• Anxiety/depression most symptom overlap, 2-4
  weeks important.
• Psychosis/mania 2-4 days sufficient in most
  cases.
• Ask about family history
• Consult multiple sources of information

157
Dual Diagnosis Treatment

• Screen for commonly comorbid conditions
• Treat comorbid conditions
• Agents which can be used safely in this
  population
• Agents with the benefit of treating both
  disorders

158
Gender Issues in Addiction Treatment
159
Learning Objectives

• Health Care Professionals will be able to
• Cite the prevalence rates of major substance use
  disorders among men and women
• Discuss different reasons for and consequences of
  use among men and women
• Describe the telescoping phenomenon and gender
  differences in physiology related to substance
  use
• Discuss gender-specific treatment

160
Epidemiology

• Men
  Women
• 
  
• Lifetime abuse/dependence
• Any Substance 35.4 17.9
• Alcohol 32.6 14.6
• Other Drugs 14.6 9.4
• 12 Month abuse/dependence
• Any Substance 16.1 6.6
• Alcohol 14.1 5.3
• Other Drugs 5.1 2.2
• 
  (Blume,1998)

161
Epidemiology (continued)

• Lifetime Rates of Use
• Men
  Women
• Alcohol 95.5 90.8
• Tobacco 50.6 38.8
• Marijuana 44.5 30.4
• Cocaine 14.0 7.2
• Hallucinogens 12.5 4.7
• Prescribed Sedatives 11.2 18.5
• Heroin 2.9 0.9

162
Gender Differences

• Reasons for Using
• Women often cite specific symptoms (e.g.,
  depression, anxiety, self-esteem), traumatic
  events, or relationship issues
• Comorbid Disorders
• Women have higher overall prevalence of
  comorbidity
• Women major depression, anxiety disorders,
  eating disorders
• Men conduct disorder, antisocial personality
  disorder

163
Order of Onset

• Men are more likely to have primary substance use
  disorders and women to have secondary substance
  use disorders
• Thus, among women, the substance use disorder
  tends to develop following another psychiatric
  condition or symptoms
• Order of onset informs etiological theories and
  has important implications for treatment
  decisions

164
Physical and Sexual Abuse

• The link between experiencing physical or sexual
  abuse and subsequent addiction is very strong for
  women
• Among women seeking treatment for substance
  abuse, up to 80 report a history of
  physical and/or sexual abuse
• This may include incidents, such as, domestic
  violence, rape, childhood sexual abuse,
  molestation, or adult sexual assault
• Important to screen for this and make appropriate
  referral

165
Physiological Gender Differences

• Telescoping phenomenon
• Women become intoxicated faster due to higher
  blood alcohol concentrations (BAC) after
  equivalent amounts of alcohol
• Women have less alcohol dehydrogenase so they
  metabolize alcohol much slower
• Menstrual cycle may also affect metabolism

166
Physiological Gender Differences(continued)

• Women are twice as likely as men to develop
  cirrhosis of the liver
• Higher mortality rates from cirrhosis among women
• More severe lung damage among women who smoke.
  Nicotine is metabolized slower in women
• Women suffer more alcohol-induced brain damage
• Women suffer more acute poisoning from substances

167
Treatment for Addiction

• Women less likely than men to seek treatment
• Most treatments developed for men
• Gender specific treatments components for women
  
• Assess psychiatric comorbidity
• Assess history of sexual or physical abuse
• Assess prescription drug abuse
• Provide education about substance use during
  pregnancy
• Offer child care services
• Offer vocational rehabilitation services
• Positive women role models among staff are
  important
• Give attention to sexism, needs of ethnic
  minority women, and needs of lesbian
  women

168
Treatment of Pain in Substance Abusing Individuals
169
Learning Objectives

• Health Care Professionals will
• Review barriers to effective pain treatment in
  addicted individuals
• Discuss acute and chronic pain management options
  in addicted individuals

170
Barriers to Effective Treatment

• Untreated pain can place an individual at risk
  for relapse, yet exposure to some analgesics
  might also trigger relapse
• Under-treatment of pain associated with increased
  morbidity and lengthened hospital stays
• Physiologic aspects of addictive disorders may
  make pain more difficult to treat
• Can be difficult to distinguish distress related
  to pain from distress related to craving

171
Acute Pain Management

• Optimize non-medication treatments
• TENS
• Ice
• Use medications without physical dependence
  properties if possible
• However, if necessary, opioid agents should be
  used
• Scheduled administration preferred to PRN

172
Use of Opioids for Pain Management in Methadone
Maintained Individuals

• Meet baseline opioid requirements in addition to
  medications for pain
• If possible, a different opioid should be
  administered for acute pain
• Increasing methadone dose to meet acute pain
  needs may complicate addiction treatment

173
Management of Chronic Pain

• Goals of treatment
• Reduction of pain
• Improvement in associated features
• Restoration of function

174
Approaches to Treatment of Chronic Pain

• Non-pharmacologic strategies
• TENS unit
• Peripheral nerve block
• Trigger-point injections
• Relaxation training
• Biofeedback
• Medications
• Try agents with less abuse potential first
• Multidimensional approach optimal

175
Conclusions

• Adequate treatment of pain necessary
• Use of opioid medications may be necessary in
  substance dependent individuals
• All modalities should be considered