Dependence and Addiction. Marek C. Chawarski, Ph.D. Yale University David Metzger, Ph.D. University of Pennsylvania

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1 Dependence and Addiction Marek C. Chawarski, Ph.D. Yale University David Metzger, Ph.D. University of Pennsylvania

2 Overview Heroin and other opiates The disease of heroin addiction or dependence Effective treatments

3 What drugs? Opiates naturally occurring or semi- synthetic derivatives of opium poppy Morphine, heroin, opium, codeine Opioid opiate opiate-like drug; acts like an opiate, but different chemical structure Fentanyl, meperidine,, methadone, oxycodone, hydrocodone

4 What is heroin? In the class of drugs known as "opiates" Extracted from the white sap of the flowering poppy plant Pure heroin is a white powder with a bitter taste Black Tar or Brown Sugar,, a gooey black or brownish substance, is a less- refined form of heroin Chemical name: diacetylmorphine

5 What does heroin look like? Pure heroin is a white powder with a bitter taste A less-refined form of heroin known as black tar or brown sugar

6 How is heroin used? Injected into a vein ( mainlining( mainlining ) Injected into a muscle ( skin( popping ) Smoked in a water pipe or standard pipe Mixed in a marijuana joint or regular cigarette Inhaled as smoke through a straw ( chasing( the dragon ) Snorted as powder Mixed with MDMA in pill form Mixed with cocaine ( speed( ball )

7 Immediate effects of heroin use Euphoria or the rush Injected into a vein: euphoria in seconds Injected into a muscle: euphoria in minutes Sniffed/snorted or smoked: euphoria in minutes Drowsiness or nodding After the initial euphoria, abusers become drowsy for several hours

8 Immediate effects of heroin use Crashing Physical symptoms of withdrawal may occur within a few hours after last drug is taken Major withdrawal symptoms peak around hours after the last dose of heroin and subside after about a week Craving Intense feeling to stop the crash and return to euphoria

9 Long-term effects of heroin use Addiction Infectious diseases (e.g., HIV/AIDS, hepatitis B and C) Collapsed veins Bacterial infections Abscesses Infection of heart lining and valves Arthritis and other rheumatologic problems Premature death

10 Use, abuse, or dependence? People start and continue to use drugs due to Recreation and experimentation Self-medication Social relationships/peer pressure Dependence and addiction Some drugs (e.g., cocaine or marijuana) can be used casually for extended periods of time Opiate use has a distinctively different pattern: people either stop or become dependent

11 Opiate dependence Preoccupation with opiates, craving Continued use despite adverse effects Loss of control - compulsive use, unable to stop or abstain, use more than intended or when didn t t intend to use Physiologic dependence tolerance withdrawal after abstaining

12 Opiate dependence Chronic disorder; high risk of persistence, relapse and recurrence Multi-factor etiology Genetic risk Psychological factors (e.g., classical and operant conditioning) Social factors (e.g., family, peers, stress) Psychiatric comorbidity (e.g., depression, anxiety) Neurobiology-- --acute and chronic effects on brain reward, anxiety and stress systems

13 Dangers of opiate dependence Premature death from overdose, infections, accidents, homicide, suicide, High morbidity-- --endocarditis,, hepatitis, phlebitis, TB, HIV and other infectious diseases Adverse impact on family and community Vocational disruption Violence and crime

14 The natural history of narcotics addiction among a male sample (N = 581). From: Yih-Ing, et. al., A 33-Year Follow-up of Narcotics Addicts. Archives of General Psychiatry, 58: )

15 Opiate dependence is a brain disease Opioids bind to brain receptors and mimic the action of natural endorphins produced by the body in response to pain Opiates affect various brain regions Nucleus accumbuns and ventral tegmental area (motivation and reward) Locus ceruleus (stress and pain) Other brain regions Chronic effects of opiate use include neuronal changes, tolerance, dependence, and withdrawal

16 Opiate dependence - Summary Untreated: high morbidity and mortality Onset and persistence affected by social, psychological, and neurobiological factors Comprehensive treatments, combining medications with counseling, are effective in reducing morbidity and mortality, as well as improving health, vocational, social, family, and legal functioning

17 Treatment modalities Pharmacotherapy Detoxification + follow-up treatment Maintenance with agonist or antagonist medications Psychosocial/behavioral treatment Outpatient counseling Self-help programs Other Residential treatments Therapeutic communities

18 Counseling in HPTN 058 protocol The HPTN 058 protocol combines medical detoxification with outpatient drug and risk counseling Half of the patients also receive agonist (Suboxone) maintenance

19 Medication alone? Detoxification alone or providing medication only (without counseling) is an ineffective long term treatment Research findings show that combining behavioral counseling with opioid agonist medications greatly increases the overall efficacy of drug abuse treatments

20 Comprehensive drug treatment Provides medications to treat drug dependence Provides counseling and referrals to address Drug- and sex-related risk behaviors Motivation Craving Psychological and emotional issues Psychiatric co-morbidity Social and family influences Emotional, health, vocational, legal and family consequences

21 Summary Drugs alter chemical processes in the brain; changes cause addiction and/or dependence Drugs detrimentally impact the user s physical and mental health, family, social and vocational functioning Drug use is associated with increased risk behaviors and criminal activity resulting in grave community impact Effective behavioral and medical treatments are available to treat addiction

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