Opiates Heroin/Prescription. Steve Hanson Director of Treatment NYSOASAS

Transcription

1 Opiates Heroin/Prescription Steve Hanson Director of Treatment NYSOASAS

2 Heroin/Opiates

3 Opiates Dates to 4,000 BC Mimics endorphin activity Natural - Opium, morphine, codeine Semi-synthetic- Heroin, Dilaudid Synthetics - Darvon, Demerol, Fentanyl

4 Modern History Off and on use through until the 60 s Man with the Golden Arm Vietnam war soldiers using heroin 1970 s increased prevalence urban areas Treatment programs Methadone Maintenance / Therapeutic Communities 1980 s Hard to find substitutes 1990 s resurgence

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6 Heroin Chic

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8 Take the best orgasm you ve ever had Multiply it by a thousand. And you re still nowhere near it.

9 Opiates Heroin more potent % - <10% in 70 s Younger age group - High School Users start with snorting - IV within 12 months Withdrawal painful - not deadly

10 NATURAL OPIATES OPIUM Morphine Codeine Thebaine

11 Semi-synthetics Morphine Heroin Dilaudid

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13 Synthetics Demerol Fentanyl Methadone Darvon

14 Opiates Fat solubility Heroin high rush Morphine lower longer onset Heroin metabolized into morphine Morphine metabolized by the liver Metabolite is 10-20X more powerful Detectable in urine for 2-4 days

15 The Action of Heroin (Morphine)

16 Tolerance Rapid tolerance with continued use Initial dose of 50mg/day can go to 500mg/day in as little as 10 days Cell sensitivity thought to be the tolerance mechanism.

17 Addiction/Dependency Opioids trigger reward system euphoria leads to continued use addiction Withdrawal symptoms are significant regular use to avoid withdrawal - dependence

18 Opiates & Reward Pathway

19 Opiates Increase DA Release

20 Opiate Effects Analgesia - change in pain perception Euphoria - whole body orgasm Sedation - on the nod Respiratory Depression - OD Cough Suppression Nausea/vomiting Constipation

21 Withdrawal Pain Depression Alert Rapid Breathing Coughing Nausea/Vomiting Diarrhea 3-5 days

22 Overdose Reversal Kits Kits can save lives Train First Responders, families, treatment staff, and PARTICIPANTS

23 Addiction vs. Dependency

24 Potency Factors by Weight Morphine 1 Heroin 3 Codeine 0.1 Dilaudid 8 Demerol 0.05 Fentanyl

25 Heroin usage patterns Highly addictive and dependence producing Significant tolerance up to 35X Increased cost Tolerance management (Tx, jail, etc.) Mixing with other opiates and other drugs (speedballing/cocaine)

26 Treatment Traditional Recovery Based/NA Naltrexone - Antagonist/Blocker Opiate Maintenance Tx withdrawal management Methadone- daily Buprenorphine/Suboxone Methadone to abstinence models

27 ED visits non-med use of Rx drugs

28 Nonmedical Use of Prescription Drugs, Ages 12+: Percent Using in Past Month Any Psychotherapeutics Pain Relievers Stimulants Sedatives Tranquilizers + Difference between estimate and the 2005 estimate is statistically significant at the.05 level.

29 Two Types of Rx Drug Abusers The Drug Abuser who likes Rx drugs. Frequently use other drugs (cocaine, alcohol, heroin, other non-rx drugs) Fits the model of a drug abuser. addicted to high The Patient who becomes dependent on their medication Infrequent use of other substances unless can t get Rx. Don t fit model of drug user age, other behaviors. dependent on the drug

30 Addiction vs. Dependency Addiction use the drug for the high, euphoria Dependent use the drug to avoid unpleasurable withdrawal effects Can be both

31 Prescription Opiates

32 Nonmedical Use of Pain Relievers in Past Year among Persons Aged 12 or Older, by Substate Region: Percentages, Annual Averages Based on

33 The Action of Opiates

34 Opiates Increase DA Release

35 Tolerance Rapid tolerance with continued use Cell sensitivity thought to be the tolerance mechanism. User now needs to find additional amounts Multiple doctors Asking friends/relatives

36 Oxycontin

37 Oxycontin Oxycodone synthesized from thebaine (part of opium) Oxycontin 1995 Crush the tablet for quicker high Oral, snort, inject Percocet oxycodone & acetominophen Percodan oxycodone & aspirin

38 Vicodin

39 Vicodin Hydrocodone and acetominophen Lorcet, Lortab Schedule III high psychological/medium physical Pain and post-surgical use (pain)

40 Issues with Rx Opiate Dependence Presence of real pain I m addicted to vicodin, not alcohol, why do I have to quit that too? Drug Testing make sure you test for drug of choice as well as alternatives.

41 Why Prescription Drug Users May Believe That They Are Different I had/have real pain, I wasn t using these to get high like those drug addicts My doctor prescribed these for me. It wasn t my idea I never robbed anyone or did those things that addicts do. I have to take something for this pain!

42 What the Rx Drug User Might Have Hitting Bottom Trouble Relating To Changing People, Places & Things Change your Lifestyle You must be completely abstinent from everything else alcohol included Going to meetings all of the time.

43 Drug Court/Treatment Issues Urine testing ensuring that the panel used includes the drugs that the participants take Medication needs people suffering from a medical/psychiatric condition that needs to be medicated which medications are okay Withdrawal risks

44 Medication Assisted Therapy & Drug Courts Clinical Perspective

45 Is Addiction a Brain Disease? Neuroimaging demonstrates drug/alcohol addiction alters brain structure & function. Similar to disease processes of mental illness & physical trauma. SPECT images from Amen 2001

46 National Institute of Drug Abuse 12. Medications are an important part of treatment for many drug abusing offenders. Medicines such as methadone and buprenorphine for heroin addiction have been shown to help normalize brain function and should be made available to individuals who could benefit from them.

47 NADCP unequivocally supports patient access to opioid replacement therapy, of which methadone is a form, when medically appropriate. Similarly, NADCP opposes attempts, no matter how well-meaning, to interfere with or otherwise undermine considered clinical judgments regarding proper treatment protocols arrived at by qualified treatment professionals overseeing the care of drug court participants. - Letter from West Huddleston to Judge Tynan (CA) 7/29/09

48 Does Treatment Work? Medications + psychosocial therapy both benefit brain function and recovery. Each affects different parts of brain and in opposite ways. PET scans adapted and retouched from Goldapple et al. 2004

49 Goals of Drug Courts Break cycle of addiction Stop/reduce criminal behavior Enhance Public Safety Cost efficient method of dealing with addiction and crime

50 Challenges to Success Relapse Craving The drugs work Changes in motivation level

51 Pharmacological Interventions Goals 1. To provide relief from withdrawal symptoms 2. To prevent drugs from working 3. To reduce craving 4. To provide aversive reactions These actions are helpful in reducing relapse and increasing retention in programs

52 Source: Childress, et al, unpublished AMYGDALAR CONNECTIVITY during brief.5 sec Cocaine Cues Placebo Drug 2 amyg conx (n=7) Baclofen blunts AMYGDALAR CONNECTIVITY Baclofen

53 Opiate Replacement Approaches 23.4% of state prisoners have history of heroin/opiate abuse - ONDCP, 2007 Methadone reduces craving, mediates withdrawal symptoms, helps restore normal brain functioning Buprenorphine/Suboxone similar purpose to methadone, may be prescribed by an MD with special training)

54 Opiate Replacement Treatment Courts/Providers reluctant to use Substituting one addiction for another Not real recovery Concerns about programs, other drugs, etc. Most of these issues are myths

55 ORT Substitutes One Addictive Drug With Another? ORT uses medication (methadone/suboxone) to overcome craving and need for illicit opioids. ORT pharmacologic actions differ from other opioids; not mere substitute. Orally effective, long acting, cross tolerance (blockade) Addictive, opioid-seeking, behaviors cease. ORT benefits overshadow reliance on dependency-producing medication. Consequences of untreated opioid addiction include: destitution, prison, disease, and/or early death.

56 MMT Patients Get High? At appropriate and adequate stable doses, normal function no lasting euphoria or sedation. Adequate methadone dose avoids extremes of intoxication or withdrawal. After dosing, some patients may sense onset of methadone effects or have vague feelings of well-being (soon wears off after blood level peaks).

57 Taming the Roller Coaster Adequate methadone smooths peaks & valleys shifting from opioid intoxication to withdrawal. Patients can live more comfortably normal lives throughout each day.

58 ORT Patients Abuse Other Drugs? ORT not a cure for addiction. Addresses illicit opioid withdrawal and craving. Pharmacologically little effect on alcohol, cocaine, etc. With adequate ORT, most patients do eliminate or reduce other drug abuse. Ongoing counseling, psychosocial treatment, needed services and self help groups are important.

59 Benefits to Drug Court Like other Chronic illnesses, a variety of treatment options are needed Evidence showing decrease in use of nonprescribed substances Decreased Criminal activity Drug Court provides support and structure that improve compliance and outcomes with MAT

60 Patient Needs Diabetes Some can control with diet Some can control with medication Some are insulin dependent Without adequate treatment - many will die Opiod Addicts Some can quit on own Some can remain abstinent with regular treatment Some need ORT Without adequate treatment - many will die

61 Benefits to Drug Court It can save lives! The treatment does work with Drug Court Fairfield County, Ohio 62% grad rate with Suboxone 13% grad rate without

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63 Methadone Effectiveness Gunne & Gronbladh, 1984 Methadone H H H H H H H H H H H H H H H H H Baseline Regular Outpatient Rx. H H H H H H H H H H H H H H H H H

64 Methadone Effectiveness Gunne & Gronbladh, 1984 Methadone P H H H H After 2 Years No Methadone P H H H H 2 P H H H H H 3 H H H D D 1 1- Sepsis & endocarditis 2- Leg amputation 3- Sepsis

65 Methadone Effectiveness Gunne & Gronbladh, 1984 Methadone After 5 Years No Methadone P P D D D P H H P D H D

66 Release from Prison - A High Risk of Death for Former Inmates RR=12 RR=4 RR=3.2 Binswanger IA et al. N Engl J Med 2007;356:

67 Relative Risk of Death 12 Causes of Death among Former Inmates Adjusted for Age, Sex, and Race Overdose Homicide Liver Disease MVA Suicide CVD Cancer Binswanger IA et al. N Engl J Med 2007;356: