402 substance use lecture fall2011

Module II Screening and Assessment

SUBSTANCE USE DISORDERSN402/511 FALL 2011

Charon Burda MS,PMHNP-BC

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Module II: Overview (11/05)

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This section is designed to give a brief overview of concepts related to substance dependence and abuse.

Healthy People 2020 http://www.healthypeople.gov

Overarching Goals:

Increase quality

Increase years of life

Eliminate health disparities

Top 10 Leading Health Indicators/Focus Areas:

Mental Health & Mental Disorders

Substance Abuse


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Healthy People 2020: Substance Abuse http://www.healthypeople.gov
SHORT TITLE ObjectiveAdverse Consequences Motor vehicle crashes/injuries Cirrhosis deaths Drug-induced deaths Drug-related emergency dept. visits Alcohol-related emergency dept. visits Alcohol- & drug-related violence Lost productivitySubstance Use & Abuse Substance-free youth Adolescent & adult use of illicit substances Binge drinking Ave. annual alcohol consumption Low-risk drinking among adults Steroid & Inhalant Use-Adol.

Healthy People 2020: Substance Abuse http://www.healthypeople.gov
SHORT TITLE ObjectiveRisk Peer disapproval of substance use Perception of risk assoc. w/ sub. abuse Treatment Treatment gap for illicit drugs Treatment in correctional institutions Treatment for injection drug use Treatment gap for problem alcohol useState & Local EffortsHospital emergency dept. referralsCommunity partnerships & coalitionsAdministrative license revocation lawsBlood alcohol concentration (BAC) levels for motor vehicle drivers
K. Fornili, Summer 2010

DHHS: Agencies in RED = those with most influence on mental health and substance abuse services http://www.hhs.gov/about/index.html


Administration for Children & Families (ACF)

Administration on Aging (AoA)

Agency for Healthcare Research & Quality (AHRQ)

Agency for Toxic Substances & Dz. Registry (ATDSR)

Centers for Disease Control and Prevention (CDC)

Centers for Medicare and Medicaid (CMS)

Food and Drug Administration (FDA)

Health Resources & Services Administration (HRSA)

Indian Health Services (IHS)

National Institutes of Health (NIH)

Substance Abuse & Mental Health Services Administration (SAMHSA)

National Institutes on Health: http://www.nih.gov/

National Institute on Drug Abuse (NIDA)http://www.nida.nih.gov/

National Institute for Alcoholism & Alcohol Abuse (NIAAA)http://www.niaaa.nih.gov/

National Institute of Mental Health (NIMH)http://www.nimh.nih.gov/


1 in 4 Americans will have an alcohol or drug problems at some point in their lives.

The number of alcohol abusers and addicts holds steady at about 16 to 20 million.

Half of college students binge drink and/or abuse other drugs and almost a quarter meet medical criteria for alcohol or drug dependence.

In 2007, approximately 204,000 high-school seniors used marijuana on a daily basis.

Substance abuse and addiction cost federal, state and local governments at least $467.7 billion in 2005.

Girls and women become addicted to alcohol, nicotine and illegal and prescription drugs, and develop substance-related diseases at lower levels of use and in shorter periods of time than their male counterparts.

Alcohol is involved in as many as 73 percent of all rapes and up to 70 percent of all incidents of domestic violence

Statistics: National Center on Addiction and Substance Abuse at Columbia University

Substance Abuse among the Military, Veterans, and their Families

The ongoing operations in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) continue to strain military personnel, returning veterans, and their families. Some have experienced long and multiple deployments, combat exposure, and physical injuries, as well as post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI).

Prescription drug abuse doubled among U.S. military personnel from 2002 to 2005 and almost tripled between 2005 and 2008.

Alcohol abuse is the most prevalent problem and one which poses a significant health risk. A study of Army soldiers screened 3 to 4 months after returning from deployment to Iraq showed that 27 percent met criteria for alcohol abuse and were at increased risk for related harmful behaviors (e.g., drinking and driving, using illicit drugs). And although soldiers frequently report alcohol concerns, few are referred to alcohol treatment.

Drugs of abuse

Nicotine

Alcohol

Marijuana (cannabis)

Heroin/opiods

Stimulants: Cocaine, Amphetamines, Methamphetamines

Hallucinogens: LSD, mescaline, psilocybin

Club drugs: MDMA (ecstacy)

PCP

Anabolic steroids

Inhalants

Prescription medications (opioid pain relievers, stimulants, CNS depressants/benzodiazepines)

DSM-IV-TR Criteria Substance Abuse

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A maladaptive pattern leading to significant distress or impairment with one or more of the following in a 12-month period:

Recurrent failure to fulfill major obligations

Recurrent physically hazardous behavior

Recurrent substance-related legal problems

Continued use despite social problems

Symptoms have never met dependence criteria


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Substance abuse refers to a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences. Individuals may repeatedly fail to fulfill major role obligations, continue to repeatedly use a substance in a situation in which it is physically hazardous (such as repeatedly driving while intoxicated), have multiple legal problems, or have recurrent social or interpersonal problems as a result of their substance use. A diagnosis of substance abuse is preempted by the diagnosis of Substance Dependence if an individual has ever met dependence criteria for that class of substance.

DSM-IV-TR Criteria Substance Dependence

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Three or more of the following at the same time in a 12-month period:

Tolerance

Withdrawal

More ingested than intended

Desire or unsuccessful attempts to reduce use

Much time involved with substances

Reduced time spent on other important activities

Continued use despite physical or psychological problems


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Per DSM-IV-TR, substance dependence refers to a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues to use a substance despite significant substance-related problems. Unlike substance abuse, substance dependence also includes tolerance, withdrawal, and a pattern of compulsive use. To meet dependence criteria, and individual must meet three or more of the listed symptoms in the same 12-month period.

Other Definitions of Addiction

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American Society of Addiction Medicine defines alcoholism as:

A primary, chronic disease with genetic,psychosocial, and environmental factors influencing its development and manifestations.

---The disease is often progressive and fatal. It is characterized by continuous or periodic: impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.


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In defining alcoholism, the American Society on Addiction Medicine uses some similar criteria, but also focuses on the concept that genetic, psychosocial, and environmental factors influence its development. This is important as it helps to conceptualize alcoholism, as well as other drug dependencies, as a disease entity itself. See West, R (2201) for review of theories of addiction.

Etiology of Substance Use Disorders

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Pathologic condition characterized by measurable changes in physiology and neurobiology

Genetic predisposition in some individuals

Environmental precipitants


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However, there has been a push in recent decades to reconsider addictions as a disease, similar to hypertension or diabetes. As with these diseases, addiction is a pathological condition with a clearly measurable, characteristic physiology and neurobiology. Furthermore, there have now been genetic factors found to be associated with substance use disorders, as well as environmental precipitants of relapse.

Genetic Factors Associated With Alcohol Dependence

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3 to 4 times higher risk in close relatives of people with alcohol dependence. Higher risk associated with:

Greater number of affected relatives

Closer genetic relationships

Severity of alcohol-related problems inaffected relative(s)

Significantly higher risk in monozygotic twin than dizygotic twin of a person with alcohol dependence

3- to 4-fold increase in risk in adopted children with a natural parent who is alcohol dependent despite being raised by adoptive parents without the disorder

(American Psychiatric Association, 2000.)


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The most data on genetic heritability of substance dependence is currently available in regards to alcoholism. Close relatives of individuals with alcohol dependence are at 3-4 times increased risk for alcohol related disorders. Significantly higher rates of concordance are found in monozygotic twins as compared to dizygotic twins. Also, adoptee studies have found that having a natural parent with alcohol dependence significantly increases risk in adopted children despite being raised by non-alcoholic adoptive parents.

NIDA: Addiction changes the brain

Dopamine Reward Pathway

Ventral tegmental area

(VTA)

Nucleus

accumbens

The VTA-nucleus accumbens pathway is activated by all drugs of dependence including alcohol

This pathway is important not only in drug dependence, but also in essential physiological behaviors such as eating, drinking, sleeping, and sex

http://www.youtube.com/watch?v=at3Sg6qvgTE

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Our Role as Nurse

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Therapeutic Alliance

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The therapist-patient relationship is a critical component of all treatment modalities

Work to establish a positive alliance at the beginning of treatment

Promote a positive therapeutic alliance

Minimize or avoid negative reactions

Avoid confrontation

Convey a high degree of empathy, confidence, and hope


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Even though there are many different types of treatments available, the therapeutic alliance (or the helping alliance between the health care professional and the patient) is a key ingredient in all treatments. The importance of the therapeutic alliance cannot be emphasized enough. This alliance begins at the very first meeting. Health care providers should try their best to establish a positive alliance with the client. Doing so will help the facilitate treatment, session attendance, compliance with treatment, and ultimately treatment outcome.

In order to establish a positive therapeutic alliance, health care providers should try to minimize or avoid all together negative interactions and reactions. Sometimes providers have negative biases or stereotypes about people who are addicted to alcohol or drugs. It is important to work through any biases or negative stereotypes so that this does not detrimentally impact the alliance or the patients treatment. Also, avoid confronting the client or using a harsh tone or demeaning language. Research has demonstrated that a confrontational style is generally not helpful and can lead to the patient being more defensive and not returning for future appointments. It is essential that the health care provider convey a high degree of empathy, confidence, and hope to the patient and his or her family.

Underlying Principles:

People are people first (not disorder);

People are deserving of

Respect; and

Access to Services;

Recovering people & their families need to be involved in their treatment & recovery;

People can and do RECOVER;

Optimism is important;

Long-term support needed;

System philosophy should ensure that Any door is the right door;

Underlying Principles:

Summer 2010

Treatment plans should be client-centered & individualized;

Maximum feasible degree of integration: Least restrictive environment that best meets needs

Culturally competent services that match communitys diversity:

Age;

Gender & Sexual Preference;

Race & Ethnicity;

INTEGRATED Mental Health and Addictions Treatment

Not sequential

Not parallel

1. ADDICTION IS FUNDAMENTALLY ABOUT COMPULSIVE BEHAVIOUR

2. COMPULSIVE DRUG SEEKING IS INITIATED OUTSIDE OF CONSCIOUSNESS

3. ADDICTION IS ABOUT 50%HERITABLE AND COMPLEXITYABOUNDS

4. MOST PEOPLE WITH ADDICTIONS WHO PRESENT FOR HELP HAVE OTHER PSYCHIATRIC PROBLEMS AS WELL

5. ADDICTION IS A CHRONIC RELAPSING DISORDER IN THE MAJORITY OF PEOPLE WHO PRESENT FOR HELP

10 things cont

6. DIFFERENT PSYCHOTHERAPIES APPEAR TO PRODUCE SIMILAR TREATMENT OUTCOMES

7. COME BACK WHEN YOURE MOTIVATED IS NO LONGER AN ACCEPTABLE THERAPEUTIC RESPONSE

8. THE MORE INDIVIDUALIZED AND BROAD-BASED THE TREATMENT A PERSON WITH ADDICTION RECEIVES, THE BETTER THE OUTCOME

9. EPIPHANIES ARE HARD TO MANUFACTURE

10. CHANGE TAKES TIME

Screening and Assessment

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At-Risk Drinking

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Per WeekPer OccasionMen>14 drinks>4 drinksWomen>7 drinks>3 drinksElders>7 drinks>1 drink

Module III: Screening & Assessment (11/05)

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Here you can see the amounts of alcohol that put individuals at risk for negative consequences. The numbers are lower for women, because women generally weigh less than men and absorb alcohol more completely and quickly from their stomachs than men do. The numbers are even lower for the elderly because of heightened sensitivity and prolonged metabolism. These numbers are based purely on research that shows that increases in negative consequences of drinking are associated with drinking these quantities.

It is important to understand that these findings are based on averages. Some individuals will be able to drink these quantities or more and not suffer negative consequences. Other individuals will suffer negative consequences with less consumption.

CAGE

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Have you ever felt you ought to Cut Down on your drinking?

Have people Annoyed you by criticizing your drinking.

Have you ever felt bad or Guilty about your drinking

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang over (Eye-Opener)

* one or more yes responses are indicative of problem drinking and further screening should be done


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Males: 2 yes suggest a current or past alcohol problem

Females: 1 yes suggests a problem

Usually on the ANCC exam

Single Alcohol Screening Question

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When was the last time you had more than

Women:4 drinks in one day?

Men:5 drinks in one day?

Positive response = within the past 3 months

Sensitivity and specificity are 86% for hazardous drinking, alcohol abuse, or alcohol dependence

(Williams & Vinson, 2000; Vinson, 2004)


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Williams R, Vinson DC. Validation of a single screening question for problem drinking. Journal of Family Practice 2001; 50P:307-312.

Vinson DC

Assessment

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Quantity and frequency of alcohol use

Other drug use: benzos, opioids, street drugs (pot and cocaine), OTC drugs

Consequences of Use: family, health, legal, work, driving while impaired

Co-occurring disorders: depression, anxiety, psychosis, suicide, PTSDT

Withdrawal symptoms: anxiety, tremor, hand shake. Does a drink make you feel better. Hx of seizures

Previous treatment attempts. What worked? What didnt work?

Readiness to change


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Over 14 drinks/week for men

Over 9 drinks a week for women

Over 2 drinks/day suggests at risk

40+drinks/week suggests dependence

Physical Assessment & Exam

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BEHAVIORAL: Hyperactivity, anxiety, aggressive violent behavior, paranoia, grandiosity, euphoria, reduced inhibition, drowsiness, sedation

COGNITIVE: memory and learning impairment

Decreased concentration, impaired judgment

SKIN: Tracking (needle marks, local abscesses

(MRSA), scars from previous abscesses, wound botulism, jaundice, rhinophyma, palmer erythema, cigarette burns, spider nevi

HEENT: Evidence of head trauma, conju.

nctivitis, constricted pupils, nasal irritation, erosion or abscess of nasal septum, periodontal disease, hoarseness, swollen parotids, alcohol on breath

Muhrer, JC.,(2010).Detecting and Dealing with Substance Abuse Disorders in Primary Care. The Journal for Nurse Practitioners 6(8) September 2010. 597-604


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Physical Assessment

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CARDIOVASCULAR: Murmur (cardiomyopathy), arrhythmias, severe hypertension, findings of subacute bacterial endocarditis

PULMONARY: Tachypnea, signs of pneumonia (community acquired aspiration) COPD, clubbing

CHEST: Gynecomastia Abdomen: Hepatomegaly, ascites, epigastric tenderness, heme positive stools, signs of pancreatitis

GENITOURINARY: decreased testicular size

MUSCULOSKELETAL: Red, swollen joints, gout, septic arthritis, SXS osteomyelitis, skeletal infections in unusual locations (sternoclavicular, vertebral) fractures

NEUROLOGICAL: slurred speech, impaired motor coordination , tremor, slowed reflexes, peripheral neuropathy, evidence of stroke

Muhrer, JC.,(2010).Detecting and Dealing with Substance Abuse Disorders in Primary Care. The Journal for Nurse Practitioners 6(8) September 2010. 597-604.

Lab testing for substance abuse

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BAC- blood alcohol content (range is 0- 500)

Toxicology screen- urine

How long substances can be detected:

* Alcohol: 3 to 10 hours

* Amphetamines: 24 to 48 hours

* Barbiturates: up to 6 weeks

* Benzodiazepines: up to 6 weeks

* Cocaine: 2 to 4 days; up to 10 to

22 days with heavy use

* Codeine: 1 to 2 days

* Heroin: 1 to 2 days

* Hydromorphone: 1 to 2 days

* Methadone: 2 to 3 days

* Morphine: 1 to 2 days

* Phencyclidine (PCP): 1 to 8 days

* Tetrahydrocannabinol (THC): 6 to

11 weeks with heavy use

Stages of change and motivational interviewing

Stages of change:

Precontemplation

Contemplation

Preparation

Action

Maintenance

Motivational interviewing:

Helps patients move further along the continuum of change (e.g., from believing they have no problem, to considering making a change, to actually making changes, to maintaining those changes)

Focused on internally motivated change

Non confrontational style

Help patients resolve ambivalence about stopping substance use

SBIRT

SBIRT stands for Screening, Brief Intervention, Referral to Treatment.

SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for people with substance use disorders and those at-risk of developing them.

Primary care, trauma centers, emergency departments, and other health care settings provide opportunities to intervene BEFORE more severe consequences of substance misuse occur.

Source: U Maryland School of Medicine

http://www.youtube.com/watch?v=orChO5Pbuoc&feature=related

http://www.youtube.com/watch?v=J-acGrReypg&feature=related

INTOXICATION AND WITHDRAWAL

The nurse should be able to recognize the signs and symptoms of:

substance INTOXICATION and

substance WITHDRAWAL

And the nursing management of both conditions

Alcohol
AlcoholBeer, wine, liquor, etc.MOAEffects of relaxation by stimulating the GABA receptors. EffectSedation, decreased inhibition, relaxation, slurred speech, nauseaOverdose effectrespiratory depression, cardiac arrestWithdrawal effectTremors, increased temp, pulse, blood pressure, delirium tremensProlonged EffectWeight loss, malnutrition, paranoid ideation, thought disturbance, stereotypical movements, amnestic disorder (Wernickes syndrome & Korsakoffs psychosis) Alcohol destroys brain cells, particularly binge drinking.

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.

Pharmacologic Treatment of Alcohol Withdrawal
MedicationsPurposeBenzodiazepines (Ativan, Valium; Librium)Administered when elevated HR, BP, T, presence of Tremors to prevent delirium tremens.Disulfiram (Antabuse)Deters individuals from drinking by causing aversive reactionsAcamprosateDeters individuals from drinking by decreasing cravings

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Opiates
OpiatesHeroin and prescription narcoticsMOAStimulate opioid receptors Effectproduce analgesia, euphoria, relaxation, constipation, constricted pupilsOverdose effectOverdose can lead to respiratory depression, coma and death. Antidote Narcan.Withdrawal effectvery uncomfortable and includes flu like symptoms, anorexia, stuffy or runny nose, dilated pupils (photophobia), piloerection and intense cravings.Prolonged EffectCriminal behavior to obtain drugs, risk infection related to needle use

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Pharmacologic Management of Opioid withdrawal

Opioid substitution

Methadone (Agonist)

Buprenorphine (Partial Agonist)

Naltrexone (Antagonist)

Non-Opioid Symptom Relief

Clonidine (tremor, agitation)

Dicyclomine (GI symptoms)

Cyclobenzaprine (muscle cramps)

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Sedatives, Hypnotics, Anxiolytics
Sedatives, hypnotics, anxiolyticsBarbituates: amytal, Nembutal, seconal, phenobarbital; Benzos: Ativan, Xanax, etc.MOAStimulating the GABA receptorsEffectEuphoria, sedation, reduced libido, emotional lability, impaired judgementOverdose effectRespiratory depression, cardiac arrestWithdrawal effectAnxiety rebound and agitation, hypertension, tachycardia, sweating, hyperpyrexia, insomnia, delirium, seizureProlonged EffectOften used with alcohol/ risk infection related to needle use

Stimulants
Stimulantsamphetamines, methamphetamine and cocaine.MOAStimulate dopamine and norepinephrine receptors. Effectheightened attention, euphoria, energy; decreased apetite, insomnia, dilated pupils, tremors, paranoia, aggressiveness, Physiologically depress appetite and cause increased T,HR and BP.Overdose effectCardiac arrhythmias/arrest, increased or decreased BP, respiratory depression, seizure, psychosis, coma, deathWithdrawal effectWithdrawal symptoms very uncomfortable and can precipitate acute depressive episode and suicidal ideation.Prolonged EffectMethamphetamine damages dopamine axons resulting in significant defects in thinking, cognitive functions and motor skills.

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Hallucinogens
HallucinogensLSD, Club Drugs (ecstasy+/-, GHB, psilocybin, mescalineMOAStimulate serotonin receptors and cause distorted perception and heightened sense of awareness Effectillusions and hallucinations. Mood and judgment impaired. Physical effects include increased T, HR and BP.Overdose effectHallucinations, paranoia, psychosis, aggression, CVA, seizures, malignant hyperthermiaWithdrawal effectNo knownProlonged EffectFlashbacks after termination of use

Inhalants
InhalantsIncludes any chemical that can be inhaled such as household cleaners, gas, solvents, glue, automotive and industrial agents, aerosol sprays MOAEffectCauses short term sense of dizziness, euphoria and altered sensation. O2 deprivationOverdose effectCNS Depression, coma, convulsionsWithdrawal effectSimilar to alcohol but milder ie. Anxiety, tremors, hallucinations, and sleep disturbanceProlonged Effectserious and permanent neurological damage and death.

Treatment

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23.48 millionAmericans neededtreatment in 2004

(National Survey on Drug Use and Health, 2004)


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Most individuals who are suffering from alcohol- and drug-related difficulties are not getting help. The 2004 National Survey on Drug Use and Health estimated that about 23.5 million Americans of age 12 and older had a current diagnosis of alcohol or drug abuse or dependence.

Access to Treatment

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440,000 (1.9%) tried butcould not get treatment

2.33 million (9.9%)received treatment

790,000 (3.4%) did nottry to get treatment

19.92 million (84.8%) feltno need for treatment


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Of those who realized they needed treatment, about 35% tried but could not get treatment, and the remainder never tried to get treatment.

Goals of Treatment

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Engage, motivate, and retain the patient in treatment

Provide education about addiction

Reduce intensity and frequency of substance use

Prevent relapse to substance use

Improve areas of life affected by addiction (e.g., employment, interpersonal relationships)

Improve the patients quality of life


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In general, the goals of substance abuse treatment are to engage, help motivate, and help to retain the patient in treatment. If the patient will not attend sessions or drops out of treatment, the potential benefits of treatment will be lost.

Treatment also seeks to help educate patients, their family members, and significant others (e.g., spouse, partner, caretakers) about addiction, its causes, consequences, and options for treatment.

Treatment aims to significantly reduce the amount and the frequency of substance use. Ultimately, the treatment goal is abstinence from use. In some cases, this may mean using a harm reduction approach and first working toward a substantial decrease (e.g., from consuming 24 beers a week to 12 a week) as a first step toward abstinence.

Once a patient has obtained abstinence or a substantial reduction in their use, treatment aims to prevent relapse and to maintain treatment gains. Given the high relapse rates across most substances of abuse, this is a particularly challenging aspect of addiction treatment. This is similar to weight loss. Losing weight is not always the hardest part; its keeping it off that can sometimes be the biggest challenge.

In addition to improving symptoms of the addiction, treatment also seeks to improve other important areas of the persons life that may have been affected by the addiction (e.g., occupational impairment, estranged relationships, poor physical health). Addressing these areas can serve to help prevent relapse. By treating both the addition and addressing important areas of functioning, the persons overall quality of life may be enhanced.

Evaluating Treatment Outcome

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Abstinence should not be the only measure

Harm or Symptom Reduction in

Substance Use

Physical health

Occupational functioning

Interpersonal functioning

Legal problems, public health and safety

Overall Quality of Life

Improvement in comorbid psychiatric disorders

Patient satisfaction and quality of life


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There are a number of different ways to assess the effectiveness of a treatment. Abstinence is only one of them and should not be the only one. Think more broadly and inquire about symptom reduction or improvement in their physical health (e.g., are they eating better, taking vitamins, keeping doctors appointments?), occupational functioning (e.g., are they employed, interviewing for jobs, performing better at current job?), interpersonal functioning (e.g., are they getting along better with family and friends, less arguments, spending more time with friends?), and legal problems (e.g., are there absence of new legal problems?).

In addition, if the patient has comorbid psychiatric conditions that may be related to their substance use (e.g., depression, anxiety) assess symptom reduction in this area, as well.

Finally, always inquire about the patients satisfaction with treatment and their overall quality of life.

Treatment Modalities

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PSYCHOTHERAPY AND SELF-HELP APPROACHES

Individual Psychotherapy

Group Psychotherapy

Cognitive Behavioral Therapy

Alcoholics Anonymous and Twelve-Step Groups

Motivational Enhancement Therapy and Motivational Interviewing

Family Therapy

Psychodynamic Therapy

Pharmacotherapy


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As you can see in this slide there are a number of different types of psychotherapy (or talk therapy) and self-help programs that are used to treat addition. Some of the most common and evidenced-based approaches which we will be reviewing include individual and group psychotherapy, cognitive-behavioral therapy, relapse prevention, AA, motivational enhancement therapy, family therapy, and psychodynamic forms of therapy. Pharmacotherapy is also extremely useful, particularly as an adjunct to psychotherapy or self-help programs. This section will review the important applications of pharmacotherapy in the treatment of addictions

Treatment facilities in Maryland

http://maryland-adaa.org/resource/

AA and Twelve-Step Groups

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Founded in 1935

A worldwide organization with over 2.2 million members

Structured around the Twelve Steps

Peer-led

Only requirement to join is a desire to stop drinking

There are similar groups nationwide for other substances and issues (e.g., Cocaine Anonymous, Narcotics Anonymous, Overeaters Anonymous, Gamblers Anonymous, Nicotine Anonymous)


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Many individuals with addiction problems find help and support by attending AA or other meetings (e.g., Narcotics Anonymous or Cocaine Anonymous). AA is structured around the 12 steps, which are listed on the following slides. AA is a peer-based organization and is led by nonprofessionals. The only requirement for joining AA is a desire to stop drinking.

AA and Twelve-Step Groups

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Advantages:

Social peer support network

Free

Offered in most urban and suburban areas

Meeting held several times per day/week

Sponsor system available 24 hours/day

WEBSITE to find meetings and other information: http://www.alcoholics-anonymous.org

Disdvantages:

Group members may insist on abstinence as only measure of success

Group members may discourage psychotropic medication for co-occurring disorders


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Some of the main strengths of AA include the social support that is provided, there is no charge to attend AA meetings or join AA, and it is offered all over the country. Meetings are held several times a day in most locations. Finally, there is a sponsor system which many people find helpful. So a person who is new to AA gets matched up with a person who has been in AA and abstinent for a while who becomes their sponsor and is available to them 24/7 if they need assistance (e.g., if they are experiencing cravings to use).

FDA-Approved Pharmacotherapies for Alcohol Dependence

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FDA = US Food and Drug Administration.

Antabuse is a registered trademark of Odyssey Pharmaceuticals, Inc.

ReVia is a registered trademark of the DuPont Merck Pharmaceutical Company

(OConnor, 1998.)

Opioid antagonist

Binds to opioid receptors, thus blockingalcohol reward pathways

Black box warning regarding hepatotoxicity

Naltrexone (ReVia)

Inhibits aldehyde dehydrogenase

When alcohol consumed, results in nausea, dizziness, headache, flushing

Decreases desire to drink

Poor tolerability profile, low efficacy

Disulfiram (Antabuse)


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Three medications are currently FDA-approved for relapse prevention to alcohol. Disulfiram has been available for several decades. It is an aversive agent that is thought to decrease the craving for alcohol by making an individual physically ill when the medication is combined with alcohol. Patients must also be warned to avoid all alcohol-containing products (such as liquid cough medicines and cooking sherry) as well as to avoid absorbing alcohol through the skin from aftershaves or perfumes. Naltrexone blocks some of the reinforcing propertied of alcohol by blocking the opioid system. Naltrexone does have a black-box warning related to its potential to cause hepatotoxicity, and should not be used in patients with hepatic impairment.

FDA-Approved Pharmacotherapies for Alcohol Dependence

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FDA = US Food and Drug Administration.

Campral is a registered trademark of Merck Sant

Indicated for maintenance of abstinence from alcohol in patients abstinent at treatment initiation

Renally cleared; contraindicated in severe renal disease

Acamprosate (Campral)


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Acamprosate also appears to decrease craving for alcohol. Acamprosate has the benefit of being renally cleared, and thus does not have the liver concerns associated with naltrexone

Methadone maintenance (heroin/opioid dependence)

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Methadone

t1/2 = 24-46 hours- once a day dosing possible

Good oral bioavailability

45-90% of patients in treatment for one year discontinue illicit opioid use

(J Health Sci Behav 29:214-226, 1988)


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With a half-life of 24 to 36 hours and good oral bioavailability, methadone is able to prevent the onset of opioid withdrawal syndrome for 24 hours or more. Methadone has also been shown to reduce or eliminate opioid craving and block the effects of illicitly used opioids.

The Role of Buprenorphine in Opioid Treatment

Partial Opioid Agonist

Produces a ceiling effect at higher doses

Has effects of typical opioid agoniststhese effects are dose dependent up to a limit

Binds strongly to opiate receptor and is long-acting

Safe and effective therapy for opioid maintenance and detoxification

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Buprenorphine differs from methadone in that it is a partial opioid agonist rather than a full agonist. The effects of the medication at lower doses are virtually the same as that of full agonists. However, as the dose is increased, the effects level out for buprenorphine (especially respiratory suppression), where they continue to increase with full agonist medications. This is called a ceiling effect. This ceiling effect greatly decreases the risk of overdose when compared to full agonists. Buprenorphine has a very HIGH affinity for opioid receptors. It displaces morphine, methadone, and other full agonist opioids from the receptor. Additionally, buprenorphine dissociates slowly from the receptor. This high affinity for and slow dissociation from the receptor result in buprenorphine blocking the effects of other opioids, such as heroin. Additionally, the high affinity and slow dissociation give rise to buprenorphines prolonged therapeutic effects. Clinical trials have demonstrated that buprenorphine is a safe and effective medication for both opioid maintenance and medically assisted withdrawal (detoxification). Additionally, because buprenorphine is very long-acting, dosing can occur on a less-than-daily basis, as infrequently as three times per week.

Drugs and alcohol kill

Decades of research have revealed addiction to be a disease that alters the brain. We now know that while the initial decision to use drugs is voluntary, drug addiction is a disease of the brain that compels a person to become singularly obsessed with obtaining and abusing drugs despite their many adverse health and life consequences. NIDA

Addiction usually begins in adolescence, thus early prevention is critical.

The 10 most important things known about addictionadd_2673 6..13

Doug Sellman

Professor of Psychiatry and Addiction Medicine, National Addiction Centre (NAC), Christchurch, New Zealand

402 substance use lecture fall2011

Health & Medicine