Heroin Addiction: Treatment Implications for Providers

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1 Heroin Addiction: Treatment Implications for Providers Geoff Wilson, LCSW, CADC The Ridge Behavioral Health Agenda How did we get here??!! Discuss the rise in Heroin use, addiction in Kentucky and across the United States. Review the impact Heroin has on the user and their ability to recover. Discuss treatment implications and options. 40 million prescriptions in 1991, up to 180 million in In the US, 82.5 prescriptions written for Opioid painkillers for every 100 Americans in 2012 In Kentucky, Opioid Pain Reliever prescriptions for every 100 people, 57.4 Benzodiazepines for every 100!! (Centers for Disease Control and Prevention, 2012) US receives 99% of world s supply of Hydrocodone. US receives 71% of world s Oxycodone. Lot of access to opiates for all ages!! 1

2 Where are our Overdoses? Overdose Deaths Top 6 counties for 2013 by overdose deaths were: 1) Bell County per 100,000 2) Clinton per 100,000 3) Breathitt per 100,00 4) Floyd per 100,000 5) Perry per 100,00 6) Harlan per 100,000 Fayette county was 27.9 per 100,000 2

3 Autopsied Cases in KY-2013 A review of cases autopsied by the Kentucky Medical Examiner s Office indicates that in 2013: Morphine was the most detected controlled substance in overdose deaths, present in 43.49% of all autopsied cases. Alprazolam was next at 34.76%, followed by 6 monoacetylmorphine (heroin) at 32%, hydrocodone at 24.79%, and oxycodone at 19.94% House Bills Have Helped Decrease in Pill Mills Several prosecutions that needed to happen! Decrease in narcotic prescriptions. More thorough oversight and much less doctor shopping. Florida has gotten on board too!! From one epidemic to another! 3

4 Guess Whose Back????? Heroin Use Increasing Across Ohio By Join Together Staff March 28, 2012 Heroin use has increased so much in Ohio that users say it is falling out of the sky, according to a new report by state health officials. Children as young as 13 are starting to use the drug, they said. Many heroin users responding to a state survey said increased demand for the drug was due to the reformulation of OxyContin, which makes it more difficult to abuse. Heroin Use on the Rise Heroin Use Increasingly Seen in Suburbs Across the Country -Join Together-April 16 th, 2013 Charlotte, NC - OxyContin a gateway to heroin for upper-income addicts Heroin in Charlotte has become so easy to get that dealers deliver to the suburbs and run specials to attract their young, professional, upper-income customers. These lawyers, nurses, cops and ministers are showing up in the detox ward at Carolinas Medical Center, desperate to kick an opiate addiction that often starts with powerful prescription painkillers such as OxyContin and Vicodin. (Health and Wellness, April 2013). "Our heroin patients," he said, "come from the five best neighborhoods." 4

5 Vermont "We've got soccer moms on heroin you walk down any street in any town in Vermont right now and chances are there is at least one house where someone is dealing with this," said Burlington Police Chief Michael Schirling, who has seen heroin trafficking cases in his area increase fivefold in just two years. "This is a completely underground, behind-closeddoors phenomenon." Chicago Heroin is the drug of choice for street gangs, says Jack Riley, a Special Agent in charge of the DEA s Chicago Field Division. He says the region s influx started about three years ago, when Mexico s Sinaloa Cartel began importing heroin through Chicago. We are seeing it in places like Indianapolis, Madison, and Milwaukee places where traditionally we really didn t see uptick in heroin. Lexington, KY Fayette County experienced 86 overdose fatalities in 2013, up from 74 in of those were specifically related to Heroin. Clay Mason, who oversees police, fire and emergency management departments in Lexington as the city s public safety commissioner, told Pure Politics that those who have overdosed cut across all demographics, ranging in their 20s to their 50s and coming from all income levels. (Jacqueline Pitts, CN/2). 1,007 overdose fatalities in 2013 statewide, compared to 1,004 in (2013 Overdose Fatality Report) 5

6 Heroin Touted As Both a Cough Suppressant and A Non- Addictive Substitute for Morphine A Little History "Heroin" is actually a brand name for Diacetylmorphine. The drug company Bayer synthesized diacetylmorphine in 1895 and branded it "Heroin." Opium and morphine, from which heroin is made, come from a variety of sources: Afghanistan -leading illegal opium and heroin exporter producing up to 82% of the world's supply. Pakistan, Southeast Asia, South America - other illegal sources Tasmania, Australia, France, Japan, the United Kingdom - sources of legal opium and heroin Heroin Heroin is an opioid drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears as a white or brown powder or as a black sticky substance, known as black tar heroin. It is from morphine that heroin is made. Morphine is made into heroin with a chemical reaction containing the chemical compound acetic anhydride. The heroin is then purified using chemical or mechanical means. 6

7 Asian Opium Poppy Plant Heroin Black Tar Heroin 7

8 Prevalence In 2011, 4.2 million Americans aged 12 or older (or 1.6 percent) had used heroin at least once in their lives. (NIDA, April 2012) Recent NIDA survey estimated that 281,000 people 12 and older regularly used heroin in 2011, up from a decade low of 119,000 in Effects of Heroin Soon after injection (or inhalation), heroin crosses the blood-brain barrier. In the brain, heroin is converted to morphine and binds rapidly to opioid receptors. Abusers typically report feeling a surge of pleasurable sensation - a "rush." Heroin is particularly addictive because it enters the brain so rapidly. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities, which may be accompanied by nausea, vomiting, and severe itching. Nodding Off Effects of Heroin Short-Term Effects: "Rush" Depressed respiration Clouded mental functioning Nausea and vomiting Suppression of pain Spontaneous Abortion DEATH!!! 8

9 Effects of Heroin Long-Term Effects: Addiction Infectious diseases, for example, HIV/AIDS and hepatitis B and C Collapsed veins Bacterial infections Abscesses Infection of heart lining and valves Arthritis and other rheumatologic problems DEATH!!! Heroin Purity Dr. Melinda Campopiano, a SAMHSA Medical Officer. When you can snort it as oppose to inject it, it widens the audience for heroin, unfortunately, she says. I think the most important driver behind the increase in number of people using heroin is its cheap, widely available, and pure enough to snort. 9

10 Impact on Brain Development Maturation Occurs from Back to Front of the Brain Images of Brain Development in Healthy Youth (Ages 5 20) Blue represents maturing of brain areas Source: Gogtay, Giedd, et al., Copyright 2004 The National Academy of Sciences, USA Gogtay, N., Giedd, J.N., et al. (2004) Dynamic mapping of human cortical development during childhood through early adulthood Proceedings of the National Academy of Sciences, 101 (21), Mid-Brain-Ventral Tegmentum Area (VTA) -The way-station for incoming sensory information on the way to the pre-frontal cortex. -Mid-Brain is the SURVIVAL Brain -What handles the next thirty seconds.reward circuitry. -Plays major role in how brain reacts to STRESS!!! -Drugs and Alcohol can become SURVIVAL. 10

11 Pre-Frontal Cortex -It confers semantic content onto objects in the world. -Seat of the self and personality -Center for love, morality, decency, responsibility, spirituality -Conscious -If it is immature, it s the neurobiological explanation for why teens/young adults show poor judgment and act before thinking. Average age of maturity? Amygdala -It integrates our emotional reactions to pleasurable and aversive experiences. -Lights up for food, sex, survival. -Lights up for cues to using and for using drugs. -As it develops, two distinct behavioral effects tend to occur: Teenagers react explosively to situations rather than calm. Teenagers have a propensity to misread neutral facial expressions as being angry/disappointed. Nucleus Accumbens -It directs motor behavior. -Is responsible for how much effort we will expand in order to seek rewards, Pay Offs. -If it is immature, adolescents and young adults will lean toward activities that require little effort, yet produce high Pay Off, like video games, drugs, etc. 11

12 Why is it so Addictive?? As a result of our use of endorphins are body is filled with opiate receptors. Heroin is basically a concentrated form of endorphins..it stimulates an endorphin rush that is much more powerful than natural. Soon after using, heroin crosses the bloodbrain barrier. In the brain, heroin is converted to morphine and binds rapidly to opioid receptors. Why is it so Addictive?? This is what makes the drug so addictive!! It hits at the very essence of what gives human beings physical pleasure.few drugs operate on the human body in such a primal fashion. Within a week or so of starting to use the drug a person will become physically addicted, making it very hard for them to stop no matter how much they might want to. Why is it so Addictive?? It s the Withdrawal Stupid!! The withdrawal is said to be some of the worst an addict can suffer through.insomnia, tremors, nausea, vomiting, stomach cramps, diarrhea, shaking, etc. It s how Heroin replaces endorphins in the body..the body becomes dependent on the unnatural high of Heroin opioids!...it begins to think that its normal to feel that constant rush Statistics show that 90% of opiate addicts will relapse within the first year after completing a traditional treatment program.. 12

13 Post Acute Withdrawal For longer term users, that isn't the end of it! This acute withdrawal is followed by a "protracted abstinence syndrome" which can continue for up to 32 weeks afterwards. The symptoms that continue over this time are: restlessness; disturbed sleep patterns; abnormal blood pressure and pulse rate; dilated pupils; feeling cold; irritability; change of personality and feeling; as well as an intense craving for the drug. Must prepare for how best to help Youth get through POW while maintaining sobriety. Co-occurring Disorders need to be addressed asap! Opiate Treatment 1) Methadone is the most commonly used medication for opioid addiction treatment in the US. Agonist maintenance with Methadone. 2) Partial-agonist maintenance with Suboxone (Buprenorphine + Naloxone) or Subutex (Buprenorphine). 3) Antagonist maintenance using Naltrexone. 4) Anti-withdrawal agents (Methadone, Clonodine) for brief, tapering periods to lead to entry into drug-free or agonists tx. Psychosocial approaches, 12-Step, abstinence-based programs alone or in combo with pharmacotherapy. In 2003, 200,000 + in US maintained on methadone. Vivitrol Vivtrol-Extended release Naltrexone- An injectable medication used to prevent relapse to opioid dependence after detox and for alcohol dependence. Need to be drug free at least 7-10 days before shot. Once a month injection- It s easier to take something once a month then thirty times a month! Literally within two weeks... it was like a light turned on in my brain," she said. "I could think again. All my thoughts were consumed with drugs. Drugs, drugs, drugs; how I'm going to get the money. This takes it away.... You can think clearly again.... It's amazing how this medicine works." Jackie P. 13

14 So What Does all this Mean?? Significant arrested development can be in play!!! Moving from abuse to dependence rapidly. For younger addicts: Lack of independence and necessary social, emotional, educational, occupational experience to enhance recovery efforts. Hep C, HIV, STDs, Psychosocial stressors. Often an enabling family system. Which means they have often not experienced the natural consequences that life will give you! Treatment, Treatment, Treatment! Will almost always need some form of Detoxification first! Inpatient treatment is recommended, especially to begin addressing co-occurring mental health/trauma. Continuous outpatient/iop level of care with Self-Help participation/residential treatment and sober living. Suboxone may be appropriate route depending upon the patient. Methadone treatment has been used for more than 30 years to effectively and safely treat opioid addiction. Relapse rate for Heroin addiction in the first year is between 80-90%. Don t get discouraged!! An Incongruence in the Field!! NIDA, SAMHSA, ASAM, and NAADAC advocate abstinence-based treatment for all DSM V substance dependence disorders: except opioid dependence, in which drug substitution treatment is considered appropriate treatment. For example, it would not be considered appropriate treatment (by most) to prescribe and maintain alcoholics on a substitution sedative/hypnotic drug such as Xanax, tell them to go to meetings and counseling, and consider that being in recovery. 14

15 Medication Assisted Treatment Drug Substitution Treatment is advocated for in the U.S. by most of the large organizations that deal with addiction including: National Institute of Drug Abuse (NIDA) Substance Abuse and Mental Health Services Administration (SAMHSA) American Society of Addiction Medicine (ASAM) National Association of Alcoholism and Drug Abuse Counselors (NAADAC) What Does Recovery Mean to You?? The idea of recovery has become popular in our culture but it is ill-defined and poorly understood. There is no real consensus among organizations such as NIDA, SAMHSA, ASAM and others that deal with substance use disorders about what constitutes recovery for opioid addiction. That fact hinders clinical practice, research effectiveness, and research outcome interpretation. As a treatment provider, it is important to answer the question: What does recovery mean to me? Level of Care Primary prevention. Early intervention. School based interventions. Outpatient/Intensive Outpatient (IOP). Partial Hospitalization/Day treatment. Adult/Juvenile drug court. Inpatient treatment. Residential treatment. Sober Living Aftercare!! 15

16 What do We Need to Keep in Mind When Working With the Young Adult? Raise the bottom!! With Heroin and Opiate Addiction we have to balance survival with abstinence based treatment. Detox is Detox the spring board for treatment. Family Therapy is critical to reduce enabling behaviors. You are often working with adolescents that look like adults.they will need activities that are active and enhance recovery behavior/vice versa Combatting PAW. 12 step programs/sponsorship are key to long-term recovery.know your groups! Relapse rate for first time Heroin treatment is about 90+%...don t get discouraged. Average number of treatment attempts for 1 years sobriety? Use the full continuum at your disposal..become more familiar with Casey s Law in KY. Treatment Dose How many treatment attempts to get one years sobriety? What s the recommended dose of treatment? Thank You!! Geoff Wilson, LCSW, CADC The Ridge Behavioral Health System 3050 Rio Dosa Drive Lexington, KY

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