Disclaimers. RECOGNITION AND TREATMENT OF OPIOID DEPENDENCE: What is Addiction and How Do You Treat It? What is Addiction? What is Addiction?

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1 RECOGNITION AND TREATMENT OF OPIOID DEPENDENCE: What is Addiction and How Do You Treat It? Disclaimers Consultant, PCSS Consultant, DEA/DOJ Consultant, BCBS Speaker, Reckitt Benckiser Carl Christensen, MD, PhD, FASAM, FACOG Clinical Associate Professor, WSU School of Med Interim Medical Director, Mich Health Prof Recovery Program Medical Director, Tolan Medical Research Clinic Past President, Mich Society Addiction Medicine Pain Recovery Solutions Ann Arbor, MI Former: Methadone provider, WSU Medical Director, Dawn Farm Associate Prof, WSU What is Addiction? What is Addiction? Physiologic Dependence? Lack of willpower? An amoral condition? A brain disease? Physiology of Addiction 5 Physiologic Dependence: Tolerance and Withdrawal Lack of Willpower? Tolerance: requiring increasing amounts of drug to get the same effect Withdrawal: the opposite effect of the drug when it is removed NEITHER of these imply chemical dependency (addiction) Physiology of Addiction 6 Physiology of Addiction

2 An amoral condition? Brain disease? Physiology of Addiction 8 Physiology of Addiction 9 The Nucleus Accumbens: GO!!! VTA: the gas tank : supplies dopamine to the Nucleus Accumbens Physiology of Addiction 10 Physiology of Addiction 11 Frontal Cortex: STOP!!!! What is the problem? Addiction is not a problem of drug WITHDRAWAL.. Physiology of Addiction

3 What is the problem? Drug WITHDRAWAL: Gardner 2006 Addiction is not a problem of drug WITHDRAWAL.. It is a problem of: CRAVING LOSS OF CONTROL COMPULSIVE USE USE DESPITE CONSEQUENCES 14 Physiology of Addiction 15 Drug ADDICTION: Gardner 2006 Why Can t They Stop????? Alcoholics/addicts who finish treatment will often relapse when they re-enter society. They will almost ALWAYS relapse if they undergo quick detox and re-enter society. But: their withdrawal is gone. SO: why do they relapse????? Physiology of Addiction 16 Physiology of Addiction 17 Abnormal response to Ritalin (methylphenidate) is due to abnormal brain chemistry Physiology of Addiction 18 Physiology of Addiction

4 I feel like I don t belong in my own skin. anonymous alcoholic Decreased Dopamine receptors =decreased Dopamine = Decreased Hedonic Tone Salsitz 2006 Can you find the (alleged) future alcoholic? Grand Physiology Rounds of Hutzel Addiction Physiology of Addiction 25 Stimulants & Blood Flow High flow Blood Flow Recovery High blood flow Non users Cocaine users, 10 days sober Healthy Control Gottschalk, 2001, Am J Psychiatry Cocaine-dependent Low flow Physiology of Addiction 27 Cocaine Users, 100 days sober Low blood flow Physiology of Addiction 28 [C-11]d-threo-methylphenidate How Long to recover from Methamphetamine? Normal Control Methamphetamine Abuser (1 month abstinent) high low SAFETY OF OPIOIDS IN CHRONIC PAIN MANAGEMENT Methamphetamine Abuser (14 months abstinent) 34 Volkow et al., J. Neuroscience,

5 Are opioids the culprit? Risks factors in opioid deaths in WV HALL et al, JAMA Dec ; 300; 22: 2613 Are opioids the culprit? Risks factors in opioid deaths in WV HALL et al, JAMA Dec ; 300; 22: 2613 Risk Factor Percentage involved History of drug abuse 78 Any diverted meds 63 Nonmedical route 22 5 Providers 21 Alcohol 17 History of previous OD 17 Illicit drug (Coc, H, meth) 16 Currently enrolled in OTP 4 ANY INDICATOR Psychotherapeutic Percentage involved ANY PSYCH MED 49 Diazepam 22 Alprazolam (Xanax ) 18 Other benzodiazepine 2 Antidepressant 16 Other 5 psychotherapeutic (AED, ambien) 36 4 prescriptions, 4 providers; dead from overdose. The real problem? WHY do doctors over prescribe? Russell Portenoy MD The Four D s: Dishonest Dated Disabled Duped

6 Chronic Pain? How to Report DISHONEST? Allegation Unit Bureau of Health Care Services P.O. Box Lansing, (517) DISABLED? Michigan Health Professionals Recovery Program Techniques to Evaluate for signs of addiction in your pain patient ADDICTION PAIN How do you recognize when you are fueling addiction rather than treating pain? Making the Diagnosis Review of Medical Records (refusal?) Physical exam: Stigmata of addiction: nicotine, opiates, cocaine Obvious intoxication/withdrawal UDS MAPS Family interviews Multiple visits, evaluate for reliability Urine Drug Screens Holy Trinity Check for meds that you have been prescribing. (missing meds = malingering) Check for meds that indicate abuse (MJ, cocaine) = addiction Remember your medication may not show up (methadone, fentanyl, suboxone) TELL THE PATIENT YOU ARE TESTING THEM FOR SAFETY S SAKE TELL THEM YOU PRACTICE UNIVERSAL SCREENING!

7 Reliance on Self Report?? Of 400 methadone maintained patients tested with saliva screening who denied recent drug use: 30% were positive for cocaine 14% were positive for heroin How do you make the diagnosis of addiction? Rule out a pure pain diagnosis You can have both!!!! Rule out malingering (selling) Use the DSM IV/V criteria or the 4 C s: (Craving, Compulsion, loss of Control & use despite Consequences) Keep asking yourself if you made the right diagnosis Cone, Addiction with Secondary Gain ( Drugstore Cowboy ) Addiction with Secondary Gain: Warning Signs 61 Friday afternoon appointments Can t tell you who their referring doc was Just moved from out of state Vague complaints, normal physical exam Asking for specific narcotics by name Most prognostic sign. 62 Pregnant? Doctor, am I going to become addicted? Overall: the incidence of iatrogenic addiction in the chronic pain patient is low. The initial estimate was 1/1000!!! BUT: The incidence of addiction in the chronic pain population is similar to the general population (15%). SO: EXPECT >5% OF YOUR PATIENTS TO SHOW ABERRANT BEHAVIOR Aronoff, 2000; Heit, 2004; Porter,

8 Do NOT continue to prescribe! ADDICTION PAIN What do you do when you realize you are fueling addiction rather than treating pain? Impression: Opioid dependence. Plan: Methadone 10 mg tabs, #240, return one month TREATMENT OF ADDICTION Twelve Step Programs Behavioral: counseling Spiritual: 12 step meetings Surgical: gastric bypass surgery MEDICAL The Gold Standard of Treatment Physiology of Addiction 68 Physiology of Addiction 69 AA involvement in Veterans 1987, 1988 Dose Response Curve

9 Does 12 step help opioid and cocaine dependence? TREATMENT OF ADDICTION: Medical Drug No mtgs % < 1 week % > 1 week % Odds Ratio Opiates * Stimulants (NS) Alcohol * % abstinent, *p 0.01 Gossop, 2007 Agonists: similar to the drug Suboxone for opiate dependence Methadone for opiate dependence Nicotine patches for tobacco dependence THC for marijuana dependence Dilaudid for heroin dependence! (Canada) 74 Physiology of Addiction 75 TREATMENT OF ADDICTION: Medical Agonists vs. Antagonists Antagonists: opposite effect of the drug Naltrexone for opiate dependence Oral: Rivea Injectable: Vivitrol NOT A NARCOTIC CANNOT BE DIVERTED Drug Type Analogy Methadone Full Agonist High Octane Buprenorphine Partial Agonist Low Octane Naltrexone/Naloxone Antagonist Water Physiology of Addiction BOTTOM LINE: In both controlled and retrospective studies, the success rate for most medications is between 40 and 60% (one to two years). When patients come off the medication, they relapse. Relapse may be associated with an increased chance of overdose and death. Physiology of Addiction 78 Benefits of Methadone Salsitz, ASAM, 2012 Reduction in death rates (Grondblah, 1990) Reduction in IVDU (Ball & Ross, 1991) Reduction in # of crime days (Ball & Ross) Reduced HIV seroconversion / HCV conversion IMPROVED OUTCOME AFTER INCARCERATION

10 Ball 1988: reduction in IVDU Ball 1988: reduction in IVDU ORT: yes or no??? 80 ORT: yes or no??? 81 Ball 1988: resumption of IVDU! Ball 1988: resumption of IVDU! ORT: yes or no??? 82 ORT: yes or no??? 83 Problems with methadone Requires initial daily dosing first 90 days. Must be clean for 2 years before you can dose monthly! Methadone clinics may be a source of wet faces and wet places Employers will frequently test for methadone and not employ methadone users, even if they are negative for other drugs. Problems with methadone: detox Withdrawal from methadone is long lasting and difficult to handle Clients will frequently take months to over one year to detox off methadone Relapse while detoxing off methadone is common Overdose and death may occur if the addict returns to using during this time

11 Buprenorphine ( Suboxone /Zubsolv ) Buprenorphine long-term follow up: Fiellin, 2008 A partial opiate agonist (less potent) Less analgesic effect Less respiratory depression <100 documented deaths in the U.S. (Soyka); PER YEAR WITH METHADONE Treats both pain and opiate dependency Different formulations are approved Addiction and Pregnancy 87 Concerns about Suboxone It can be abused (mostly for withdrawal) It is unsafe when combined with sedatives & alcohol. It is an opioid. Relapse rates after detox exceed 90%. (Weiss, 2011) Vivitrol (injectable naltrexone) for opioid dependence 89 Vivitrol: abstinence Vivitrol: craving

12 Vivitrol: concerns As with methadone and buprenorphine, when the medication is stopped, relapse may lead to death due to lack of tolerance. It is difficult to treat acute pain while on Vivitrol. The GOLD STANDARD of treatment: 85% success Pilots, Lawyers and Healthcare Prof. Continuous monitoring: 3 to 5 years. Therapist, Group, 12 step, sponsor Immediate intervention for relapse Graded response Why does it work? IQ? 94 The GOLD STANDARD of treatment: 85% success Hawaii's Opportunity Probation with Enforcement (HOPE) Continuous monitoring Treatment / 12 step Rapid consequences Graded response Doc, when can I get off this sh*t? Can you detox? Maintenance vs. Detox? 101 women underwent detox during pregnancy 40 successfully detoxed. No adverse fetal effects documented Luty et al, J Sub Abuse Treat 24 (2003); heroin addicts were started on Suboxone. 20 were detoxed off and offered counseling. 20 were kept on Suboxone and offered counseling. A year later. ORT: yes or no??? 99 ORT: yes or no???

13 102 ORT : yes or no??? 103 ORT : yes or no??? Why Treat Addiction? Drug Dependence, a Chronic Medical Illness: McLellan 2000 Only about 40% of patients will be abstinent at one year after treatment. Failure rates may be due to lack of aftercare, often due to insurance difficulties Low economic status, psych comorbidity and lack of family/social supports also predict relapse. Relapse is often viewed as inevitable and drug dependence as hopeless * Drug Dependence, a Chronic Medical Illness: McLellan 2000 ONLY 60% OF TYPE I DIABETICS ADHERE TO MEDICATION SCHEDULE LESS THAN 40% OF ASTHMATICS ADHERE TO TREATMENT REGIMEN LESS THAN 40% OF HYPERTENSIVES ADHERE TO THEIR TREATMENT REGIMEN DRUG DEPENDENCE =40 TO 60% ADHERENCE Addiction: a chronic illness If you were to stop taking your insulin, and you wound up in a coma in the ICU, your doctor would say: you need to go back on insulin! You could have died! If you were to stop your Suboxone/methadone/ 12 step treatment, and wind up in the ICU, your doctor would say: You re an addict. You re hopeless!!!!!

14 Chronic, Treatable but Incurable Diseases Contact info: Carl Christensen Obesity Hypertension Diabetes Asthma Addiction Cell: Patients: Physiology of Addiction 115 Physiology of Addiction

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