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A BioPsychoSocial Update of Substance Use Disorders

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A BioPsychoSocial Update of Substance Use Disorders George Kolodner, M.D. Kolmac Clinic gkolodner_at_kolmac.com DC EAPA July 19, 2012 – PowerPoint PPT presentation

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Title: A BioPsychoSocial Update of Substance Use Disorders


1
A BioPsychoSocial Update ofSubstance Use
Disorders
  • George Kolodner, M.D.
  • Kolmac Clinic
  • gkolodner_at_kolmac.com
  • DC EAPA
  • July 19, 2012

2
Substance Use by Kolmac Patients
1989 2011
Cocaine 44 12
Opioids 6 31
Marijuana 6 23
Benzodiazepines 2 9
3
High School Drug Use Patterns(www.monitoringthefu
ture.org)
  • Utilization is stable for overall drug use
  • Dramatic increase in prescription opioids
  • Increase in marijuana
  • Decrease in cocaine and methamphetamine

4
Rise in Pill Abuse Forces New Look at U.S. Drug
Fight NY Times, July 17
  • Overdose deaths
  • 20,000 from prescription drugs
  • 16,000 from illicit drugs
  • Shifting the policy focus from cocaine and heroin
    to prescription drugs
  • Mexico shifting from reducing drugs to reducing
    violence and corruption
  • Reduction in cocaine use (5.8 ? 1.5 million)
  • Due to success of interdiction or decreased
    demand?

5
BioPsychoSocial 3 Inter-related Aspects of
Person and Disease
  • Biological substance persons physiology
  • Sedative vs. stimulant, purity, route of
    administration
  • High tolerance, opioid receptor sensitivity,
    dopamine receptor level, ADHD
  • Two types of drug addiction damages
  • Hijackers Mega doses of internal chemical
  • Opioids, nicotine, cannabis
  • Smashers External impact on multiple sites
  • Alcohol, cocaine and other stimulants

6
BioPsychoSocial 3 Inter-related Aspects of
Person and Disease
  • Psychological
  • Expectation and setting
  • Personality (who has the disease)
  • Other psychiatric disorders
  • Social
  • Legal vs. illegal
  • Legality and regulations constantly changing
  • Availability and customs

7
Drug Control vs. Drug Treatment
  • Drug Control (Supply Side) 60 funding
  • What substances should be legal and how should
    they be regulated?
  • What are the most effective social responses to
    people who use illegal drugs or do not abide by
    the regulations for legal substances?
  • Drug Treatment (Demand Side) 40 funding
  • What are the bio-psychological effects of
    psychoactive substances?
  • What is the most effective treatment approach for
    people who develop substance use disorders?

8
Drug Control Issues
  • Prohibiting a substance for which there is a
    demand creates a pseudo-monopoly for criminals

9
Prices of Illegal Drugs
  • Cocaine retail price of one gram in 2011 177
  • 74 cheaper than 1981
  • 16 cheaper than 2001
  • Heroin and methamphetamine similar reductions
  • Marijuana no significant price reduction
  • NY Times, 7/12

10
Cost and Use of Legal Drugs
  • Alcohol
  • Raising the price of alcohol by increasing excise
    tax reduces heavy and binge drinking without
    affecting light to moderate use
  • Paying The Tab, Philip Cook. 2007
  • Tobacco
  • Increasing the price of cigarettes reduces use,
    particularly by youth
  • Increased use of lower taxed mini-cigars by youth

11
Social Issues
  • Drug violation arrests 1.64 million in 2010
  • 80 of possession, half for small amounts of
    marijuana
  • NYC, 2011 85,000 drug misdemeanor arrests at
    1,500 to 2,000 each
  • Imprisonment for drug offenses
  • 50 of federal prisoners
  • 20 of state prisoners
  • Reduced public concern about drug abuse (Gallup
    poll)

12
Pain Pill Epidemic
  • How Did We Get Here?

13
Brief History of Pain Pills 1
  • Apprehension of physicians to medicate pain dates
    back to 1914 Harrison Narcotic Act
  • Criminalized opioid dependency
  • Both addicts and treating physicians were jailed
  • It is still illegal for physicians to prescribe
    opioids to an opioid addict for addiction
  • Blurred line between treating pain or treating
    addiction

14
History 2, 1990s Concern About Under
Medicating of Pain
  • Pressures on physicians to be more aggressive
  • 1999 Pain as the Fifth Vital Sign promoted by
    Veterans Administration, Joint Commission, and
    State of California
  • Reassurances from pain management specialists
    about addictive potential of opioid pain
    medications

15
History 3, 1996 Oxycontin
  • Long acting formulation of oxycodone
  • Oxycodone introduced in 1917 because of concern
    about addictive properties of heroin, which had
    been introduced in 1898 because of addictive
    properties of morphine
  • Promoted by Purdue-Pharma for its safety
  • Fines for misrepresentation, other suits pending
  • Capsule altered for snorting and injection
  • Spread opioid addiction to rural America
    (hillbilly heroin)

16
History 4 Pain Mills
  • Physicians established high volume practices that
    dispensed pain pills for cash
  • Wide variation in regulation by states
  • Broward County, Florida became infamous
  • DEA enforcement influenced by pain lobby

17
History 5 Internet Sales
  • Complex international organizations eluded
    enforcement efforts
  • Illustration Try internet search for oxycodone
    no prescription
  • Impact limited by expense and unreliability

18
Update on Treatment of Opioid Addiction
Buprenorphine
  • Improved clinical results when patients stay on
    buprenorphine longer
  • Physicians reaching 100 patient limit
  • Some diversion, especially of mono form
  • But better treatment results for patients who
    used street buprenorphine
  • Resistances within the addiction field
  • Professional 28 day residential treatment
    centers
  • Recovery community Narcotics Anonymous
  • Some states do not allow physicians on
    buprenorphine to return to practice

19
Buprenorphine vs. Methadonein Pregnancy
  • Same incidence of neonatal abstinence syndrome
    (NAS)
  • Less severe NAS with buprenorphine
  • 89 less medication
  • 43 less hospital days
  • More discontinuation of buprenorphine than
    methadone because of dissatisfaction with
    medication

20
What Are We Getting Into?
  • Coming to a Dispensary Near You
  • Medical Marijuana in DC

21
Changes in Marijuana Use
  • Utilization is up among high school students
  • 2010 reversal of downward trend
  • www.monitoringthefuture.org
  • Purity is up
  • Based on DEA street buys

22
Possible Changes in Legal Status
  • Current DEA Controlled Drug Status
  • Marijuana Schedule 1
  • Synthetic THC (dronabinol, Marinol) Schedule 3
  • Decriminalize
  • Manage offenses with fines instead of
    incarceration
  • Legalize for recreational use
  • Regulate and tax like alcohol
  • Legalize for medical use
  • Exists in 17 states plus D.C. (First California,
    1996)
  • Physicians are not the driving force in this
    effort

23
Arguments For and AgainstMedical Marijuana
  • FOR People are suffering from medical conditions
    that respond to smoked marijuana and no other
    medication, including dronabinol.
  • AGAINST Marijuana is a complex substance taken
    via a high potency route of administration. It
    should therefore be subjected to the same quality
    standards and dosing studies as any other
    pharmaceutical, dispensed through traditional
    pharmacies, and regulated by the FDA.

24
DC Medical Marijuana Regulations(Chapter 99
Definitions, pp. 113-114)
  • Qualifying medical condition means
  •  
  • (a) Human immunodeficiency virus
  •  
  • (b) Acquired immune deficiency syndrome
  •  
  • (c) Glaucoma
  •  
  • (d) Conditions characterized by severe and
    persistent muscle spasm, such as multiple
    sclerosis
  •  
  • (e) Cancer or

25
DC Medical Marijuana Regulations
  • (f) Any other condition, as determined by
    rulemaking, that is
  •  
  • (1) Chronic or long lasting
  •  
  • (2) Debilitating or interferes with the basic
    functions of life and
  •  
  • (3) A serious medical condition for which the use
    of medical marijuana is beneficial
  •  
  • (1) cannot be effectively treated by any ordinary
    medical or surgical measure or
  •  
  • (2) For which there is scientific evidence that
    the use of medical marijuana is likely to be
    significantly less addictive than the ordinary
    medical treatment for that condition

26
Continued Legal Ambiguities
  • DOJ Memo, 10/09 Federal government would not act
    against marijuana in states where its use for
    medicinal purposes was legal
  • DOJ Memo, 6/11 Persons who are in the business
    of cultivating, selling, or distributing
    marijuana, and those who knowingly facilitate
    such activities, are in violation of the
    Controlled Substances Act, regardless of state
    law.

27
Implementation Problems
  • Qualifying medical conditions
  • California pseudo medicalization de facto
    recreational legalization
  • Dosing and purity
  • Relationship with physician
  • Addressing drugged driving
  • California thug factor

28
Possible Resolution
  • Keep specific diagnostic indications
  • Remove catch all category
  • Allow for exceptions on a case by case basis

29
Marijuana Negative Effects
  • Evidence for residual negative impact on
    executive cognitive functions
  • Attention, concentration
  • Ability to plan, organize, solve problems, make
    decisions
  • Physical addiction documented
  • Withdrawal symptoms
  • Increased blood pressure
  • Insomnia
  • Irritability
  • Anxiety
  • DSM-5 has new diagnosis for Cannabis Withdrawal

30
Marijuana Treatment Issues
  • Marinol for detoxification and maintenance
  • Initial research studies have not been promising
  • Difficulty being taken seriously in Narcotics
    Anonymous
  • Marijuana Anonymous available
  • Cultural problems in young adults
  • Persistent use of alcohol by marijuana addicts
  • Persistent use of marijuana in other addictions

31
Tobacco
  • The Elephant In The Room
  • Addressing Tobacco Addiction In Treatment
    Programs For Substance Use Disorders

32
Annual Mortality
  • Kills 50 of the people that use it
  • USA
  • Nicotine 440,000
  • Alcohol 100,000
  • All other drugs 36,000
  • Worldwide 4.9 million
  • Projected by 2020 to kill 10 million people and
    become the 1 cause of death

33
Secondhand Smoke Annual Impact
  • Smoke from burning end of cigarette is more toxic
    than smoke that is inhaled
  • 53,000 deaths of non-smokers
  • Compares with 11,000 deaths from drunk drivers
  • 35,000 from heart attacks
  • 3,000 from lung cancer
  • Young children are especially sensitive
  • Under 18 months 300,000 cases of pneumonia and
    bronchitis
  • 26,000 develop asthma

34
Correcting Mistaken Beliefs
  • Lung cancer is not the biggest medical danger
  • Only 15 of smokers develop lung cancer
  • Tobacco is the 1 risk factor for heart attacks
  • Risk is reduced by 50 one year after quitting
  • Tobacco is leading cause of COPD
  • Nicotine is addicting but not toxic
  • No major medical consequences from nicotine
    except slower wound healing after surgery
  • Nicotine patch does not slow healing

35
Tobacco Utilization in USA
  • Reduced in adults
  • 1964 40 ? Now 20.6
  • Higher in people with substance use disorders
  • Alcoholics 34 to 56
  • Drugs 52 to 68
  • Highest in patients in treatment for SUDS
  • 65 to 85 (especially methadone)
  • Tobacco shortens life span of recovering
    alcoholics

36
Paying Lip Service to AddictionChanging Our
Language
  • Tobacco user ? tobacco addict
  • Smoking cessation ? tobacco addiction
    rehabilitation
  • Ex-smoker ? recovering smoker

37
Similarities to Other Addictions
  • Continued use despite adverse consequences
  • Genetically influenced
  • Rapid metabolizers more susceptible to physical
    dependence than slow metabolizers
  • Withdrawal symptoms are acute and protracted
  • Relapses are common and occur in response to the
    standard 3 triggers
  • Exposure to substance
  • Cues (conditioned learning associations)
  • Stress

38
Differences from Other Addictions
  • Greater certainty of toxic effect but more
    extended length of time to develop
  • 12 step support (Nicotine Anonymous) struggles
  • Greater tolerance of use by recovery community
  • Research money is managed by National Cancer
    Institute not National Institute of Drug Abuse
  • Insurance coverage is very limited

39
Treatment The Easier Way
  • Adequate nicotine replacement treatment
  • Ignoring package instructions and media
    negativity
  • BGE
  • Intensive group based rehabilitation
  • Use traditional addiction treatment concepts
  • Continued care group therapy

40
Medication Options
  • Nicotine replacement (detoxification)
  • Long acting patch
  • Short acting
  • Non-prescription gum, lozenges
  • Prescription nasal spray, inhaler
  • Electronic cigarette unregulated and not
    recommended
  • Wellbutrin/Zyban (buproprion)
  • Chantix (varenicline) nicotine receptor agonist
  • Over-reaction about causing depression and heart
    problems

41
Mayo Clinic Treatment Program
  • Higher doses of multiple medications for 3 to 6
    months or more
  • Remove withdrawal as an issue
  • Standard recommendations are inadequate
  • Fear of nicotine toxicity is misplaced
  • Use for as long as it takes
  • This is not an infectious disease.
  • 8 day residential program 52 1 year quit rate

42
Tobacco And Traditional Addiction Rehabilitation
  • New Jersey joins New York in prohibiting tobacco
    in residential rehabilitation
  • No integration with Mayo SUDs program
  • Stones on the windowsill
  • Eliminating tobacco breaks at Kolmac

43
Integrating Treatment of Tobacco Addiction Into
Addiction Programs
  • Challenging the belief that this will interfere
    with recovery
  • Addiction treatment programs as enablers of
    tobacco addiction
  • Most users express the desire to quit
  • How to address this and respect the desire of
    others not to quit
  • Importance of not activating negative side of
    ambivalence by mandates and reminders of dangers

44
Benzodiazepines
  • Increased use is over-shadowed by pain pill
    increase
  • No overdose deaths
  • Usually in combination with opioid or alcohol
    addiction
  • Hard to convince prescribing physicians,
    especially psychiatrists, to avoid with addicted
    patients because of general safety
  • Important of exceptions

45
Newest Substances In Pursuit of What Is Not Yet
Illegal
  • Designer drugs, club drugs, salvia
  • Synthetic marijuana (spice, K2)
  • Sold as incense
  • Use is up to 11 of youth
  • Bath Salts
  • A synthetic stimulant, can cause psychosis
  • Active ingredient is cathinone (DEA Schedule I)
  • Found naturally in khat (cot), a shrub native
    to East Africa and southern Arabia

46
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