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


1
Module IIOverview of Substance Use Disorders
Section A Overview of Addiction
Project MAINSTREAM
November 2005
2
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

3
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

4
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

5
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

6
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.

7
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
8
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).
9
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)
10
Dependence or Abuse of Specific Illicit Drugs
among Persons Aged 12 or Older 2003
Numbers (in Thousands) of Users with Dependence
or Abuse
11
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
65
Age in Years
12
Tobacco Use among Persons Aged 12 or Older 2002
and 2003
Percent Using in Past Month
13
Tobacco Use among Youths Aged 12 to 17 2002 and
2003
Percent Using in Past Month
14
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
15
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
16
Substance Dependence or Abuse among Adults Aged
18 or Older, by SMI 2003
Percent Dependent or Abusing in Past Year
17
Co-Occurrence of SMI and Substance Use Disorders
among Adults Aged 18 or Older 2003
18
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
19
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.)
20
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

21
Stigma and Addictions
  • Moral weakness/character flaw
  • Treatment doesnt work

22
DISEASE Model of Addictions
  • Pathologic condition with clearly measurable,
    characteristic physiology/neurobiology
  • Genetic predisposition/environmental precipitants

23
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

24
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.)
25
Neurobiology of Addictions
  • Excellent animal models
  • Multiple neurotransmitter systems
  • Dopaminergic
  • Serotonergic
  • Opiate
  • Excitatory amino acid systems
  • HPA axis - stress relapse models

26
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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34
Section BOverview of Addiction Treatment
35
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

36
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

37
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

38
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

39
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

40
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

41
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)

42
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

43
Section CTreatment Modalities
44
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

45
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

46
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

47
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

48
Individual Therapy
49
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

50
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)

51
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

52
Group Therapy
53
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

54
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

55
Cognitive-Behavioral Therapy
56
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.

57
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.

58
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

59
Alcoholics Anonymous (AA) and Twelve-Step Groups
60
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)

61
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

62
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.

63
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.

64
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.

65
Motivational Enhancement Therapy (MET) and
Motivational Interviewing (MI)
66
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

67
Family Therapy
68
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.

69
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

70
Psychodynamics and Addiction
71
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

72
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

73
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

74
Pharmacotherapy
75
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

76
Pharmacotherapy (continued)
  • Ideal Pharmacologic Addictions Treatment
  • Low abuse potential
  • Safety
  • Agents that treat both disorders

77
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

78
Section DPharmacotherapy Treatments
79
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

80
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

81
Ideal Pharmacologic Treatment
  • Low abuse potential
  • Safety
  • Agents that treat both disorders if dual diagnosis

82
Pharamcotherapy for Drugs of Abuse
  • Less evidence available
  • Cocaine
  • Marijuana
  • Club drugs
  • Well-studied or proven treatments
  • Alcohol
  • Opioids
  • Nicotine

83
Alcohol
84
Pharmacotherapy Overview Alcohol
  • Withdrawal
  • Benzodiazepines/anticonvulsants
  • Relapse prevention
  • Disulfiram
  • Naltrexone
  • Acamprosate

85
Alcohol Withdrawal Protocols Benzodiazepines
  • Fixed dose taper
  • Loading dose Oral, IV, IM
  • CIWA Triggered
  • Clinical PRN

86
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

87
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

88
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.)
89
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
90
Disulfiram in the Treatment of Alcohol Dependence
(Azrin et al., 1982)
91
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

92
Alcohol Treatment (Pharmacologic)
93
Acamprosate
  • Inhibits ionotropic metabotropic glutamate
    receptors (mGluRs)
  • FDA-approved for maintenance of abstinence from
    alcohol in alcoholic patients who are abstinent
    at treatment initiation

94
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

95
Non-FDA Approved Medications Under Study
  • Ondansetron
  • Topiramate
  • Many others

96
Opioids
97
Pharmacotherapy Overview Opioids
  • Detoxification
  • Opioid detoxification
  • Medication assisted detoxification
  • Relapse prevention
  • Naltrexone
  • Maintenance
  • Methadone
  • LAAM
  • Buprenorphine

98
Detoxification
  • Opioid substitution
  • Methadone (Agonist)
  • Non-Opioid Symptom Relief
  • Clonidine
  • Dicyclomine
  • Cyclobenzaprine
  • Naltrexone

99
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

100
Naltrexone for Relapse Prevention
  • Long-acting opioid blocker
  • Limited effectiveness
  • Poor compliance
  • Poor treatment retention
  • Depot formulation may offer promise

101
Maintenance Treatment
  • Methadone
  • Gold standard
  • LAAM
  • Pulled from market in 2004 due to QTc
    prolongation
  • Buprenorphine
  • Newly approved
  • Partial agonist

102
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

103
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)
104
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

105
Buprenorphine/NalxoneSuboxone
  • A partial mu agonist a mu antagonist in a 41
    ratio
  • 20.5 mg 41 82 164 S.L.
  • Mono form Subutex

106
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

107
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)

108
Cocaine
109
Pharmacotherapy Overview Cocaine
  • Acute intoxication/withdrawal
  • Relapse prevention

110
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

111
Treatment of Acute Cocaine Intoxication
  • Physiologic hyperexcitability
  • Hypertension, tachycardia, hyperthermia, seizures
  • Supportive treatment
  • Benzodiazepines
  • Seizure treatment with diazepam, phenobarbital,
    or phenytoin

112
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

113
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

114
Nicotine
115
The 5 As for Brief Intervention to Treat Tobacco
Dependence
116
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

117
Medications to Target Nicotine Addiction
  • Nicotine replacements
  • Nicotine patch, gum, inhaler, lozenge, nasal
    spray
  • Antidepressants
  • Bupropion
  • Nortriptyline
  • Other
  • Clonidine

118
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

119
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

120
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

121
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

122
Marijuana
123
Medications to Treat Marijuana Withdrawal
  • Positive outcomes
  • Nefazodone
  • Oral THC
  • Negative outcomes
  • Divalproex
  • Bupropion

124
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

125
Potential Advances
  • Cannabinoid antagonists
  • Rimonabant likely to be FDA-approved for smoking
    cessation and obesity
  • May play role in treatment of marijuana dependence

126
Club Drugs
127
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
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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
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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
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