Disclosure INTRODUCTION TO SUBSTANCE USE DISORDERS. Substances of Abuse. Substances of Abuse. Primary Substance Use Disorders

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1 INTRODUCTION TO SUBSTANCE USE DISORDERS Disclosure Some slides courtesy of Dr. D. Charney Co-owner 38DTX private treatment center Ronald Fraser, MD, CSQP, FRCPC Assistant Professor McGill University Dalhousie University Primary substance intoxication substance withdrawal substance abuse substance dependence Amphetamines Barbiturates Benzodiazepines Caffeine Cannabis Hallucinogens Substances of Abuse Substances of Abuse Dopamine D2 Receptors are Lower in Addiction Inhalants Nicotine Opioids Phencyclidine Designer Drugs (MDMA, GHB, Ketamine) Meth Reward Circuits Non-Drug Abuser Heroin Control Addicted Reward Circuits Drug Abuser 1

2 Secondary substance-induced psychotic disorder substance-induced mood disorder substance-induced anxiety disorder substance use affects presentation of all primary psychiatric disorders greater impulsivity, aggression, dysphoria and suicidality; poorer judgement one of the most common, costly health problems in Canada and the US Direct and indirect costs are estimated at over $4 billion annually in Canada extensive medical, psychiatric and social complications use of health care services 2% of all ER visits in QC are substance-related (MSSS) 1% of premature death is caused by hazardous drinking (Ogborne, 2) motor vehicle accidents 5% of fatal MVAs involve alcohol (Ogborne, 2) legal problems extensive medical, psychiatric and social complications lost employment suicide 5% of suicide attempts / completions involve alcohol (Ogborne, 2) family violence alcohol is implicated in over 3% of cases of childhood violence and sexual abuse in QC (MSSS) enormous consequences for families and children ½ of adults in the US have a family member who has or has had alcohol dependence (Dawson & Grant,1998) NESARC: 12-Month Prevalence of Substance Use Disorders alcohol use disorder 8.46% any alcohol abuse 4.65% any alcohol dependence 3.81% (Grant et al., 26) any drug use disorder 2.% any drug abuse 1.37% any drug dependence.63% (Stinson et al., 26) NESARC: 12-Month Prevalence of Substance Use Disorders if you have an alcohol use disorder, then the risk of any drug use disorder 13.5% any drug abuse 8.4% any drug dependence 5.1% if you have a drug use disorder, then the risk of any alcohol use disorder 55.17% (Stinson et al., 26) Prevalence of SUD younger > older individuals men > women unemployed > employed large > small metropolitan areas race, culture, religion psychiatric illness another SUD family history of SUD 2

3 Vicious Cycle of Addiction Genetic Risk Factors Financial, Social, Legal, Medical Problems Anxiety/Low Mood Consuming Mood Altering Substance 4x increased risk for alcoholism among first-degree relatives of alcoholics, with higher vulnerabilities for those with a greater number of alcohol-dependent close relatives (Prescott and Kendler, 1999; Schuckit, 22) genetic > familial, as shown by adoption and twin studies (Goodwin et al., 1973; Heath et al., 1997; Prescott and Kendler, 1999) children adopted away from alcoholic homes remain at 4X increased risk children adopted into alcoholic homes have comparable risk to the general population MZ:DZ concordance is approximately 2:1 - Beck, 1993 Disinhibition / Impulsivity a different set of genes affects disinhibition and impulsivity enhanced sensation seeking difficulty learning from mistakes associated with a variety of externalizing conditions conduct disorder and ASPD associated with an enhanced vulnerability for drug dependence correlated with several neurophysiological measures low-amplitude P3 wave of the event-related potential (ERP) low levels of serotonin (5HT) specific D2, D4, T or SERT alleles hypothesized subtypes of alcoholism Cloninger s Type 2 Babor s Type B What is Heavy Drinking? WHO defines heavy drinking in terms of the amount of EtOH that confers an elevated risk of negative health consequences 4 drinks per day or 2 drinks per week for MEN 3 drinks per day or 12 drinks per week for WOMEN sex differences due to differences in body fat composition, enzyme levels, etc. telescoped course of problem drinking among women (inc. liver damage) (Porjesz et al., 22; Slutske et al., 1998) What is a Standard Drink? 1 standard drink is equal to 13.1 g of alcohol 12 oz. (355ml) of regular beer (5%) pint = 16 oz. king can = 95 ml the boss = 1.18 ml 2 beer at 8% = 11 drinks, 2 beer at 1% = 14 drinks 5 oz. of regular wine (12-17%) 1 bottle of 25 oz / 75 ml = 5 standard drinks 1 1/2 oz. of hard liquour (8-proof) 1 bottle of 4 oz / 1.14 L = 27 standard drinks DSM-IV-TR Criteria for or Drug Abuse A maladaptive pattern of substance use; 1 (or more) of 4 criteria: 1) recurrent substance use resulting in a failure to fulfill major role obligations at work/school/home 2) recurrent substance use in situations in which it is physically hazardous 3) recurrent substance related legal problems 4) recurrent substance use despite having persistent social or interpersonal problems caused or exacerbated by the effects of the substance Never met criteria for dependence for this substance. 3

4 DSM-IV-TR Criteria for or Drug Dependence A maladaptive pattern of substance use; 3 (or more) of 7 criteria: 1) tolerance need for more drug to achieve desired effect diminished effect with use of same amount 2) withdrawal characteristic withdrawal syndrome substance is used to relieve / avoid withdrawal DSM-IV-TR Criteria for or Drug Dependence 3) substance used in larger amounts, or for longer periods than intended 4) persistent desire or unsuccessful efforts to cut down or control substance use DSM-IV-TR Criteria for or Drug Dependence 5) a great deal of time is spent obtaining, using or recovering from substance 6) important social, occupational, or recreational activities are reduced or given up because of substance use 7) substance use continues despite knowledge that is has negative effects on physical or psychological health Specify with or without physical dependence. Course of chronic, relapsing disorders good outcomes measured in terms of longer periods of remission shorter periods of use / lesser amounts improvements in physical health enhancement of psychosocial functioning Assessment for Addiction Treatment Assessment includes a review of the kinds of situations, moods and behaviors that pose the highest risk for use / relapse internal triggers (e.g. emotional states, such as sadness, anger or boredom) external triggers (e.g. social pressures to drink) deficits and strengths in coping resources needed to address these triggers level of readiness to change Scientifically-Based Approaches to Addiction Treatment Cognitive behavioral interventions Community reinforcement Motivational enhancement therapy 12-step facilitation Contingency management Pharmacological therapies Relapse Prevention Principles of Drug Addiction Treatment: A research-based guide (Revised 29). National Institute on Drug Abuse 4

5 NI: Selected Principles of Effective Treatment (EBPs) 1. Addiction is a complex but treatable disease that affects brain function and behavior. 2. No single treatment is appropriate for everyone. 3. Treatment needs to be readily available. 4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. 5. Counselling individual and/or group and other behavioural therapies are the most commonly used forms of drug abuse treatment. NI: Principles of Effective Treatment (EBPs) cont d 6. Many drug-addicted individuals also have other mental disorders. 7. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change longterm drug abuse. 8. Treatment does not need to be voluntary to be effective. 9. Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases. MUHC Addictions Unit Addictions Program MUHC Addictions Unit of the Department of Psychiatry, McGill University Health Centre Multidisciplinary mental health team Abstinence oriented approach Waiting list of 6 weeks 3 clients assessed annually, covered by Quebec health insurance Mostly outpatient, 3 beds for inpatient detox Adults, primarily English-speaking Training Readmission PRN Research Referral Phase I Phase II Consultation Phone Intake Assessment Discharge Phase I (6 weeks) Conventional Treatment One individual therapy session (5 min.) and one group therapy (1.5 hours) session per week Therapeutic interventions are motivational, psychoeducational, cognitive-behavioural Phase II (6 months) Primarily group therapy, once to twice weekly Therapeutic interventions: cognitive-behavioural, supportive, and psychodynamic Percentage Completing Outpatient Treatment Completers - 5.7% % % % Paraheratakis et al., 2 5

6 % Remaining in Detox % Remaining in Treatment Median Length of Stay in Outpatient Treatment Retention - Outpatient Treatment Patients - 18 days Sedatives-Hypnotics days - 84 days - 37 days Days of Follow Up Paraheratakis et al., 2 Paraheratakis et al., 2 Percentage Completing Inpatient Detoxification Median Length of Stay Sedatives-Hypnotics - 8% - 79% % - 46% Sedatives-Hypnotics- 24 days days - 16 days - 13 days Completers Patients Fraser et al., unpub. Fraser et al., unpub. Retention - Inpatient Detoxification Psychotherapy Options motivational enhancement therapy cognitive behavioral therapy twelve step facilitation relapse prevention therapy cue desensitization therapy Days of Follow Up Fraser et al., unpub. 6

7 Pharmacotherapy Options detoxification protocols - minimize withdrawal symptoms anti-relapse medications - increase likelihood of abstinence postdetoxification psychiatric medications - treat comorbid psychopathology Anti-Relapse Medications for Dependence alcohol-sensitizing drugs disulfiram, calcium carbamide opioid antagonists naltrexone, nalmefene glutamate antagonists acamprosate serotonergic agents fluoxetine, citalopram, odansetron other agents topirimate 7