Science and Treatment Prescription Drug Addiction Treatment. Karen Miotto, M.D. David Geffen School of Medicine

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1 Science and Treatment Prescription Drug Addiction Treatment Karen Miotto, M.D. David Geffen School of Medicine

2 Presentation Objectives Examine drugs: effects, toxicities, withdrawal Explain how drugs work Understand how prolonged drug use changes brain circuitry Understand how appropriate options treatment

3 Who has Prescription Drug Problems? Youths Fasted growing prescription abuse group Youths obtain prescription opioids from peers, family, and friends Elderly Includes pain patients who abuse opiate medication Users typically have co-morbid medical and psychiatric conditions Baby Boomers Used drugs in the 1960 s & 1970 s Ling ppt, 2005

4 Medical uses of Stimulants FDA-Approved: ADHD, ADD Nacrolepsy Off-Label: Depression augmentation Medically ill Weight suppressant

5 Prescription Stimulants Methylphenidate (Ritalin/Concerta) Methylphenidate patch (Daytrana) Dextroamphetamine (Dexedrine) Amphetamine/dextroamphetamine (Adderall) Lisdexamfetamine (Vyvanse) Long vs. short-acting Abuse risk: availability, past SUD, co-occuring psychiatric dx, little support, uninformed MD

6 Stimulants Desired Effects: Euphoria Increased energy/productivity Increased concentration Decreased appetite Decreased sleep Increased libido Toxic Effects: Irregular heartbeat High body temperatures Seizures Irritability Paranoia Risk of progression to amphetamine/ methamphetamine use NIDA 2008

7 Stimulant Withdrawal Feeling sad, depressed, and/or suicidal Extremely tired and sleepy Stimulant cravings Hard to concentrate Anxiety Decreased energy Don t care about anything (apathy) Drug dreams

8 Central Nervous System (CNS) Depressants Sedatives, Benzodiazepines, Tranquilizers Prescribed Indication: anxiety, panic attacks, sleep disorders and muscle tension Effects: relaxation, sleep, decreased worry Toxic Effects: memory problems, frequent falling, tolerance and respiratory depression, overdose and death Withdrawal : seizures anxiety, insomnia and confusion Heighten sensitivity to sound touch and smell Long lasting discomfort NIDA 2008

9 Opioids/Opiates/Pain Pills Prescribed Indication: Important and essential medications for pain relief Generic and trade names: oxycodone (OxyContin) hydrocodone (Vicodin) meperidine (Demerol) Desired Effects: Pain relief, euphoria, well-being, relaxation, increased energy Toxic Effects: respiratory depression, overdose, death SAMHSA 2003

10 Opioid Withdrawal Symptoms Bad Flu Body aches muscle/bones Nausea, vomiting, diarrhea, abdominal pain Runny nose, sneezing Yawning Tearing eyes Sweating/chills Goosebumps, yawning Restless, anxiety Insomnia, fatigue, Note: Physical dependence and/or tolerance does not necessarily equal addiction

11 What is Addiction? A brain disease expressed as a compulsive behavior The continued abuse of drugs despite negative consequences A chronic, relapsing disorder

12

13 However Advances in science are changing our fundamental views of drug abuse and addiction, showing us that: Drug abuse is a preventable behavior Drug addiction is a treatable disease

14 Why Do People Take Drugs in The First Place? To feel good To have novel: feelings sensations experiences AND to share them To feel better To lessen: anxiety worries fears depression hopelessness

15 Why Do People Take Drugs in The First Place? Instrumental use or functional use: instrumental drug use' has been used to denote drug use for specific drug effects (WHO, 1997) Examples of the instrumental use: Drivers who report using stimulants to improve concentration and relieve tiredness Using stimulants (not prescribed by a doctor) to lose weight

16 Vulnerability Why do some people become addicted to prescription drugs while others do not?

17 Biology/genes Biology/ Environment Interactions Environment Drug Availability and Acceptability

18 Risks of Becoming Addicted Broad availability of prescription drugs e.g., via the medicine cabinet, family, friends, Internet, and physicians Misperceptions about their safety Focus on a pill for every ill (cultural trend, media) High rates of other substance use including abuse cigarettes, drugs and alcohol High rates of other psychiatric problems

19 How are drugs addicting?

20 Circuits Involved In Drug Abuse and Addiction All of these must be considered in developing strategies to effectively treat addiction

21 Reward System Schick Shadel Hospital, 2009

22 Positive and Negative Reinforcements Positive Reinforcements: when a pleasure-inducing action becomes repetitive controlled by various neurotransmitter systems Negative Reinforcements: the motivation to use a substance in order to avoid discomfort result of adaptations produced by chronic use within the same neurotransmitter systems

23 Drug Addiction: A Complex Behavioral and Neurobiological Disorder Historical - Prior experience - Expectation - Learning Environmental - Social interactions - Stress - Conditioned stimuli Drugs Brain Mechanisms Physiological - Genetics - Circadian rhythms - Disease states - Gender Behavior Environment

24 Relapse Rates Are Similar for Drug Addiction & Other Chronic Illnesses 100 Percent of Patients Who Relapse to 60% 30 to 50% 50 to 70% 50 to 70% 0 Drug Addiction Type I Diabetes Hypertension Asthma McLellan et al., JAMA, 2000.

25 Treatment and the Cycle of Addiction

26 Treating a Biobehavioral Disorder Must Go Beyond Just Stopping the Drug Pharmacological (medications) Detoxification Relapse Prevention Behavioral Therapies Medical and Social Services Family Services Mutual Help Meetings

27 Youth Prescription Abuse Youth obtain prescription opioids from peers family and friends Limiting access to prescriptions Prevention programs Prescription drugs NIDA Studies for Adolescent Substance Abuse Family Intervention (CTN-0014) Brief Strategic Family Therapy Buprenorphine/naloxone-Facilitated Rehabilitation (CTN-0010)

28 Universal Precautions Analgesia (Pain) Is the patient getting better pain relief? Adverse effects (Price) Are there side effects, such as falling down, sedation..? Activities (Performance) Is the patient functioning, getting out of the house? Aberrant behaviors (Pees) Are regular drug of abuse screens negative for illicit drugs and positive for the drug being prescribed?

29 Older People and Prescription Abuse Higher incidence of chronic conditions Misunderstand directions Multiple prescribers Medication sharing Rationalization and denial among family members, peers or care providers Deficits presumed to be due to age Interaction with alcohol or other drugs Analgesic rebound anxiety or pain syndrome

30 Analgesia Universal Precautions (Pain) Is the patient getting better pain relief? Adverse effects (Price) Are there side effects, such as falling down, sedation..? Activities (Performance) Is the patient functioning, getting out of the house? Aberrant behaviors (Pees) Are regular drug of abuse screens negative for illicit drugs and positive for the drug being prescribed

31 Treating Opioid, Stimulant and CNS Depressants Abuse/Addiction Treating opioid addiction: Detoxification or Maintenance Methadone, Buprenorphine, Naltrexone Treating stimulant addiction: Support during withdrawal Cognitive-behavioral therapy Recovery support groups Treating CNS depressant addiction: Detoxification Counseling, recovery programs SAMHSA 2003

32 Recommendations DO NOT flush pills down the toilet because: Sewage systems can t remove these medicines from water that is released into lakes, rivers or oceans Fish and other aquatic animals have shown adverse effects from medicines in the water

33 Proper Disposal of Prescription Drugs Mix prescription drugs with an undesirable substance will further ensure that drugs are not diverted I.e., used coffee grounds, kitty litter Community pharmaceutical take-back programs also allow public to bring unused drugs for proper disposal 2007 Office of National Drug Control Policy

34 We Need to Treat the Whole Person and the Whole Village! In the Social Context Educate the Community, the Children, the Healthcare Providers Increased Prescription Monitoring Working in Conjunction with Law Enforcement

35 Strategies to Address the Problem Improve diagnostic criteria Focus on compliance Standardize prescription labeling Analyze age-related changes in drug abuse Develop treatment programs tailored to elderly Consider dual diagnosis Examine impact of internet/foreign purchase of medications Examine ethnic and cultural differences Patterson ppt

36 Behavioral/Psychological Treatments for Pain and Addiction Education Cognitive-behavioral therapy Biofeedback/relaxation Family therapy Functional rehabilitation Mood disorder therapy 12 step recovery John F. Brandt

37 Resources for Treatment Substance Abuse and Mental Health Services Administration National Clearinghouse for Alcohol and Drug Information,

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