Identification, treatment and support for individuals with Alcohol & Drug Addiction in the Community

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1 Identification, treatment and support for individuals with Alcohol & Drug Addiction in the Community Dr David Jackson Clinic Medical Officer The Hobart Clinic Association

2 Drugs In tonight s context, drugs are substances that are psycho-active. (i.e. alcohol and caffeine, too) Drug use is normal. Addiction (dependence) is not just drug use but a complex bio-psycho-social phenomenon (i.e. a disease) with major genetic and physiological components. 2

3 Definition of addiction A chronic, relapsing disease characterized by compulsive drug-seeking and by longlasting chemical changes in the brain. Addict is a term that originated in Roman law, when it referred to a person who was formally made over or bound [to another] or attached by restraint or obligation. 3

4 Drug/alcohol Dependence Difficulties in controlling substance-taking behavior A strong desire or sense of compulsion to take the substance Progressive neglect of alternative pleasures or interests Persisting with substance use despite clear evidence of overtly harmful consequences Evidence of tolerance A physiological withdrawal state when substance use has ceased or been reduced (ICD-10) 4

5 In the community 10% adults alcohol dependent 25% nicotine dependent Chronic conditions Complicated by other diseases Bio-psycho-social in origin So, of necessity, are seen by GPs Copyright 2014 The Hobart Clinic 5

6 Cause of addictions Biological: genetics and neurochemistry Psychological: genetics again involved Social factors Copyright 2014 The Hobart Clinic 6

7 Genetics Twin and adoption studies, animal studies Heritability of 50 to 85%, depending on drug Impact on drug effects, tolerance, withdrawal syndromes, psychiatric co morbidity Affect treatment responses 7

8 Neurochemistry: dopamine Most drugs (but not benzos) increase dopamine levels D2 knockout mice (which don t have dopamine receptors) don t get the pleasure High D2 receptor levels cause discomfort Anticipation raises dopamine levels 8

9 Other relevant neurotransmitters Opioids Glutamate Cannabinoids GABA Serotonin CRF NPY 9

10 Opioids Mu receptor vital in addiction no mu, no addiction, no withdrawal system Increase in receptors in cocaine and opioid dependent people (so craving) Kappa reduces dopamine activity and causes dysphoria 10

11 Glutamate Principal excitatory neurotransmitter Link to dopamine in reward system Receptor (NMDA) plays role in addiction to nicotine, alcohol, BZDs, cannabis Increased activity at NMDA in withdrawal, causing fits and cell death 11

12 Cannabinoids CB1 receptor necessary for opioid reward and withdrawal syndrome 12

13 GABA Activity increased by BZDs so increased brain inhibition No dopamine involvement 13

14 Serotonin MDMA, MDA, MDEA raise serotonin (and dopamine) levels Fluoxetine blocks MDMA uptake Reduced levels in alcohol dependence 14

15 Current Treatments 15

16 The 12 principles of treatment 1. No single treatment is appropriate for all individuals. 2. Treatment needs to be readily available. 3. Effective treatment attends to multiple needs of the individual, not just his or her drug use. 16

17 4. An individual's treatment plan must be assessed continually and modified as necessary to meet the person s changing needs. 5. Remaining in treatment for an adequate period of time of is critical for treatment effectiveness. 17

18 6. Counselling (individual and/or group) and other behavioural therapies are critical components of effective treatment for addiction. 7. Medications are an important element of treatment for many patients, especially when combined with counselling and other behavioural therapies. 18

19 8. Addicted individuals with coexisting mental disorders should have both disorders treated in an integrated way. 9. Detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. 19

20 10. Treatment does not need to be voluntary to be effective. 11. Treatment programs should provide assessment and counselling for HIV/AIDS, hepatitis B and C, and other infectious diseases. 20

21 12. Recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment. 21

22 Alcohol Treatment Withdrawal: benzodiazepines, vitamins Abuse: Brief interventions, motivational interviewing, CBT, pharmacotherapy, esp. naltrexone Dependence CBT, MET, 12-step, disulfiram Naltrexone, acamprosate, ondansetron, Rimonabant, GHB, topimirate, baclofen, varenicline 22

23 Tobacco CBT NRT Bupropion Varenicline Nortriptyline 23

24 Cannabis Anxiolytics/antipsychotics for acute toxicity Brief intervention, motivational interviewing and CBT for dependence Treat co-existing problems (anxiety disorders, depressive illnesses and psychosis may all precede heavy cannabis use) 24

25 Psychostimulants Acute: diazepam/haloperidol (danger of seizures Chronic: Limited therapies CBT Bupropion, substitution 25

26 Benzodiazepines Slow reduction, or maintenance therapy Pregabalin 26

27 The Future Largely determined by neuroscience better understanding, better treatments, more chance of prevention Needs application of research findings already lagging behind in attitudes and delayed treatments 27

28 Like most diseases, will require the bulk of the work to be done in primary care with specialist back up 28

29 Contact details Dr David Jackson The Hobart Clinic Tel: Web: 29