7th annual chair summit -...

#CHAIR2014

Sponsored by

September 11 – 13, 2014 | Westin Tampa Harbour Island

CHAIR SUMMIT7TH ANNUAL

Master Class for Neuroscience Professional Development

#CHAIR2014

Douglas M. Ziedonis, MD, MPH University of Massachusetts Medical School UMass Memorial Health Care Worcester, MA

Substance and Alcohol Abuse

Douglas M. Ziedonis, MD, MPH

●  No financial arrangement or affiliation with pharmaceutical or device commercial interests

●  Research/Grants: National Institutes of Health; SAMHSA; Veterans Affairs; Massachusetts Department of Mental Health; Foundation for Mental Health Excellence; Physicians Foundation

●  Advisory Board: RiverMend Health/RCA Holdings LLC; Skyland Trail

●  Board of Directors: National Network Depression Centers; UMass Memorial Behavioral Health Services; Community Health Link; Marlborough Hospital; Massachusetts Hospital Association

Disclosures

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Incorporate changes from DSM-IV to DSM-V criteria in your clinical management of patients with substance use disorder (SUD)

Learning Objective 1

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Assess emerging substance-use problems, including tobacco-related products, club drugs, etc

Learning Objective 2

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Develop a treatment plan and integrate pharmacotherapy, psychosocial treatments, and community resources in to the management of the patient with SUD

Learning Objective 3

DSM-5 Substance-Related and Addictive Disorders ●  Substance Use Disorders (SUD)

!  No Abuse and dependence – only SUD !  SUD has 11 criteria

!  All DSM-IV dependence & ¾ abuse (no legal) + Craving !  now severity level is key (3 levels): Mild: 2-3 sx; Moderate: 4-5;

Severe: >6 !  No poly-substance category - each substance a unique disorder

●  Intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders have separate criteria and unique diagnostic category !  Added cannabis withdrawal and caffeine withdrawal

●  Addictive Disorders/Non-Substance-Related Disorders !  Gambling Disorder official !  Not now – perhaps in future: Food Addiction, Internet, Sex, Spending,

Work, Co-dependence, etc

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition: DSM-5. Washington, DC: American Psychiatric Association; 2013.

DSM-5 Criteria for Substance Use Disorders: Recommendations & Rationale

Hasin DS, et al. Am J Psychiatry. 2013;170(8):834-851.  PMID:  23903334  

Figure Legend:

DSM-5 Criteria for Substance Use Disorders: Recommendations & Rationale

Hasin DS, et al. Am J Psychiatry. 2013;170(8):834-851. PMID: 23903334.

DSM-5 Substance Use Disorders (11 Criteria)

●  Impaired control (criteria 1- 4) ●  Social impairment (criteria 5 - 7) ●  Risky use (criteria 8 - 9) ●  Pharmacological criteria (criteria 10-11) ●  DZ version: 4 Cs and 2 biological symptoms: ●  4Cs: Control (loss of), compulsive use, continued use

despite consequences, and craving !  Wanting, craving, and needing

●  2 Biological criteria: Tolerance and withdrawal

Cs = cravings Hasin DS, et al. Am J Psychiatry. 2013;170(8):834-851. PMID: 23903334.

Reward, Memory/Learning, Motivation, & Inhibitory Control/ Executive Function Areas to consider in developing new treatments

Circuits Involved In Addiction

Garavan H, et al. Am J Psychiatry. 2000;157(11):1789-1798. PMID: 11058476.

Garavan H, et al. Am J Psychiatry. 2000;157(11):1789-1798. PMID:  11058476.  

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Cocaine Film Erotic Film

Controls

Cocaine Craving Population (Cocaine Users, Controls) x Film (Cocaine, Erotic)

Cocaine Users

Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older: 2011

Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings Website http://www.samhsa.gov/data/nsduh/2k11results/nsduhresults2011.pdf. Publshed September 1012. Accessed September 7, 2014.

Emerging Products, Substances and Resources

● Tobacco and nicotine ● Prescription drugs ● Club drugs ● Combinations ● Resource for updates on emerging

products - www.erowid.org

Emerging Tobacco Products: Smokeless Tobacco Products

Electronic Cigarettes (E-Cigs)

E-Cigarette

● Not FDA approved ● Not proven as cessation aides –

patients may use ● Could be harmful &/or addictive ● Attracting adolescents

! Thousands of flavors, including candy, chocolate, bubble gum

● Technologically appealing ● Cost

! $140 one month supply

Snus: Unfiltered

●  Teabag-like pouch of dry snuff originating in Sweden

●  á snuff use is on the rise in men aged 18-44 and daily cigarette smokers

●  From 2002-2007 !  37-53% of smokeless tobacco users also

smoked ●  Cross-promotion with other tobacco

products !  Dual use and addiction

●  Steam cured vs. air cured !  Less harmful, not harmless

Snus: Unfiltered

● 20 pouches for $2.50-$5.00 ! 8 mg nicotine/pouch

● All major tobacco companies have recently purchased smokeless tobacco companies

● Not advisable as a harm reduction or cessation aide

● American Snus vs. Swedish Snus ! Strong manufacturing, marketing,

regulation differences Snus for sale at local airport terminal

Emerging Tobacco Products

● Hookahs and water pipes ● Little cigars

Cigar Products: Unfiltered

●  Cigars, cigarillo, and little cigars ●  Single cigars or packs

!  Ex. Double Diamonds !  $1.50 / pack of 20

!  Ex. Black and Milds !  65 cents for a single !  $5-7 / pack of 5

●  Flavors still permitted ●  Just as harmful and addictive

!  More puffs, nicotine, CO, tar ●  Alternating between cigarettes

and cigars ●  Many do inhale

!  Falsely believed less harmful

RYOs (Roll-Your-Owns): Unfiltered

● From 2007-2008 ! Cigarettes â 4.2% ! RYO á 14.9%

● Sold as “pipe tobacco” to be cheaper ! RYO â 61% ! “pipe” tobacco á 233%

● Higher levels of ! Carbon monoxide ! Nicotine ! Tar

Emerging Tobacco Products: Smokeless Tobacco Products ● Dissolvables

Orbs Lozenges

Strips Sticks

Dissolvable: Unfiltered

● Finely milled tobacco, flavorings, etc. ! $3-4 each ! 4 types of ground tobacco

● Strips (20) ! .6mg nicotine in 3 minutes

● Sticks (10) ! Resemble toothpicks in dippers pouch ! 3.1mg nicotine in 10-30 minutes

● Orbs (Small pellets, 15) ! 1mg nicotine in 15 minutes

● Lozenges

K2/Spice and Bath Salts

● Synthetic cannabinoids “K2/Spice” ! Sold as Incense ! Agonist laced on leaves !  Smoked and in tea

● Synthetic stimulants “Bath Salts” ! Methylenedioxypyrovalerone (MDPV),

mephedrone ! Synthetic cathinones similar to

cathinone (khat) ! Oral, IN, IV, or Smoked

COD Assessment Strategies

● Specific substances and symptoms ● Time-line (prior history) ● Prior mental health, addiction, and dual

diagnosis treatment ● Information from significant others ● Family history ● Changes while in treatment COD = Co-occurring disorders Miller G. ed. Learning the Language of Addiction Counseling John Wiley & Sons. Hoboken, NJ. 2010.

Dual Recovery Status Exam

● Assess current mental status ! Psychiatric/withdrawal symptoms

● Assess last substance use ! Cravings/thoughts

● Assess for motivational level/changes ● Assess treatment involvement ! Medication adherence ! 12-Step/recovery activities

Assessing Motivation to Change

● Precontemplation, contemplation, preparation, action, maintenance

● Formal: SOCRATES and URICA ●  Informal:

! Importance, readiness, and confidence rulers ! DARN-C ! Decisional balance ! Time-line/quit date ! Counter-transference and non-verbal cues

SOCRATES = Stages of Change Readiness and Treatment Eagerness Scale; URICA = University of Rhode Island Change Assessment; DARN-C = Desire, Ability, Reason, Need, and Commitment Prochaska JO, et al. Am Psychol. 1992;47(9):1102-1114. PMID: 1329589.

Dual Recovery Therapy

●  Integrate and modify traditional addiction psychosocial treatments ! Motivational Enhancement Therapy ! Relapse prevention ! 12-Step facilitation ! Mindfulness based interventions

● Blend evidence-based mental illness treatments ! CBT ! Social Skills Training

●  Individual, group, couples, family therapy

MET = MI + Feedback

● Motivational Interviewing (Style) ! Empathy, respects readiness to change, embraces

ambivalence, and directive ! OARS: Open-ended questions; affirmations; reflective

listening; summaries ● Personalized Feedback (Content)

! Assessment, including motivational level ! Decisional balance: pros and cons ! Personalized feedback ! Change plan, shared decision-making, and menu of

options MET = Motivational interviewing and personalized feedback

CBT: Relapse Prevention

●  Identifying cues / triggers for substance use or cravings / thoughts

● Do an analysis of a “relapse” ● Goal to improve self-efficacy to avoid / handle

specific people, places, things, moods, other addictive acts, etc

● Examples: Drug refusal skills, seemingly irrelevant decisions, managing moods / thoughts, and stimulus control

CBT = Cognitive Behavior Therapy Guichenez P, et al. Rev Mal Respir. 2007;24(2):171-182. PMID: 17347604.

Applied Mindfulness: RAIN

●  Recognize !  “I’m feeling anxious”

●  Accept/allow !  See if you are resisting the experience

●  Investigate !  “What’s happening in my body right now?”

●  Note !  Label or mentally note the body sensations from moment to

moment

Brewer JA, et al. Psychol Addict Behav. 2013 Jun;27(2):366-379. PMID: 22642859 http://www.mindful.org/mindful-magazine/craving-to-quit, Judson Brewer, MD, PhD author

12-Step Facilitation

● Accepts disease model ● Encourages use of 12-Step social network, including

sponsor and home group ● Coach “working their program” ●  Fellowship and higher power are the agents of

change - spirituality key ●  Initial labeling of self as alcoholic is encouraged to

address denial, minimization, and rationalization ● Abstinence model - loss of control with use ● Acceptance, Surrender, and Get Active

Is the Patient Working Their 12-Step Program?

●  Working the steps ●  Sponsor, mentor, or guide ●  Group support and involvement ●  Self-evaluation ●  Spiritual Activity – Connection to Higher Power (prayer,

meditation, ..) ●  Daily reading or reflections ●  Health care (recreation, exercise, diet, tobacco) ●  Celebrate successes ●  Being of service to others

Medications for COD Treatment

● Detoxification ● Protracted abstinence ● Harm reduction /opioid agonists ● Co-occurring Psychiatric Disorders ! AA Brochure: The AA Member: Medications

and Other Drugs, 1984

COD = Co-occurring disorders Alcohol Anonymous. AA Brochure: The AA Member: Medications and Other Drugs. http://www.aa.org/assets/en_US/aa-literature/p-11-the-aa-membermedications-and-other-drugs. 2011.

Principles of Pharmacology for COD ●  Consider specificity of psychiatric & addiction disorders ●  All medications are not created equal

!  Abuse liability !  Safety !  Interaction with substances

●  Avoid psychiatric medications with abuse liability, overdose risk, causing seizure, sedation, liver toxicity, sedation

●  Simplify dosing strategies (start low – go slow) ●  Stress education and compliance ●  Psychology to taking pills for an addict ●  Minimize refills ●  Resources: CO-MAP & TIPS & APA & VA guidelines CO-MAP = Co-occuring, Motivation, Awareness, Practice TIPS = Treatment Improvement Protocol Series

Medications for Alcohol Dependence

● Detoxification ! Benzodiazepines ! Barbituates

● Protracted abstinence ! Disulfiram ! Acamprosate ! Naltrexone

Smith H, et al. Guideline Watch: Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd Edition. American Psychiatric Press. Arlington, VA 2010. 2010.

Treatment Outcomes in AUD Medication Studies

●  Days abstinent (%) ●  Days heavy drinking (%) ●  Abstinence rate (any drinking) ●  Heavy drinking (different quantities used) ●  Drinks per drinking day ●  Time to first drink/relapse ●  Consequences of drinking ●  Biological markers

AUD = Alcohol use disorder

Disulfiram – FDA Approved

●  Blocks liver enzyme (acetaldehyde dehydrogenase) & blocks CNS dopamine decarboxylase – increases dopamine theoretically

●  Alcohol / antabuse interaction: Facial flushing, throbbing headache, nausea, vomiting, increased blood pressure and heart rate

●  Monitoring and enhancing compliance is key ●  Monitor ingestion ●  Usual dose: 250 mg daily ●  Blood monitoring of liver function tests – baseline / q 3 months ●  Inexpensive - generic ●  Rare – but high dosages (1,000 mgs) have had a few patients

develop psychotic symptoms

PI for disulfiram. Drugs@FDA Website.http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=a49396ee-da77-42df-b94c-130d2fb3dfbc. 1951

Naltrexone – FDA Approved ●  FDA approved for opiates and alcohol

!  Naltrexone (Revia): alcohol dependence !  Nalrexone (Trexan): opioid dependence !  Naltrexone XR Injectable (Vivitrol)

●  High-affinity opiate antagonist ●  Opiate antagonism mechanism – increase dopamine levels ●  Opiate free for 7 days prior to start – ask about pain meds ●  Could do narcan challenge ●  Oral dose 50mg daily ●  Card in wallet – that on naltrexone (ER) ●  Liver function tests monitored

!  baseline and every 3 months

PI for naltrexone hydrochloride. Drugs@FDA Website.http://www.accessdata.fda.gov/drugsatfda_docs/nda/2000/75-434_Naltrexone%20Hydrochloride_prntlbl.pdf. 2000

Acamprosate – FDA Approved

●  NMDA modulator (partial agonist) ●  FDA approved and used in Europe ●  1998 mgs (two 333 mgs tablets TID) ●  Increases abstinence rates and time to first relapse ●  Increased treatment retention

!  Mechanism: reduce protracted withdrawal symptoms & cue induced craving – by balancing GABA (inhibitory / brakes) and glutamate (excitatory/ gas)

●  Side effects: mostly diarrhea (15%) !  Others noted: GI abdominal pain, neurasthenia, reduced libido,

pruritus, occasional rash

PI for acamprosate. Drugs@FDA Website.http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021431s015lbl.pdf. 2012.

Medications for Cocaine or Amphetamine Dependence

● Detoxification: ! Symptom relief

● Protracted abstinence: ! None are FDA approved

Medications for Opiate Dependence

● Detoxification: Methadone, clonidine*, clonidine/naltrexone*, buprenorphine ● Protracted abstinence: Naltrexone ● Harm reduction/maintenance:

Methadone, buprenorphine

* = This agent is not FDA approved for opiate dependence Smith H, et al. Guideline Watch: Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd Edition. American Psychiatric Press. Arlington, VA 2010. 2010.

Treatment Outcomes Summary

Definition ● 1-year retention

in treatment ● Elimination OR

significant reduction in illicit opiate use

● Methadone: 50%-80% ● Buprenorphine: 40%-50% ● Naltrexone: 10%-20% ● Drug-free tx: 5%-20% ● Detoxification: 5%-20%

Tobacco Use Assessment and Treatment Plan

● Current Use ! What using? How much? ! Heaviness scale: TTF and cigarettes/day ! Assess patterns of use - triggers, associations

● CO meter or cotinine level ● Current motivational level ● Past quit attempts ● Support or lack of support ● Medications and medical problems

Medication Algorithm

● Monotherapy (any of 7 FDA med choices) ! Varenicline ! Patch ! Oral nicotine replacement therapy (NRT) ! Bupropion

● Combination pharmacotherapy ! Multiple NRTs ! Patch and oral NRT

! Bupropion and NRT Hughes JR. J Subst Abuse Treat. 2013;45(2):215-221. PMID: 23518288.

Tobacco Smoke & Psychiatric Medication Blood Levels

●  Smoking induces the P450 1A2 isoenzyme secondary to the polynuclear aromatic hydrocarbons

●  Smoking increases the metabolism of some medications !  Haloperidol, fluphenazine, olanzapine, clozapine, thioridazine,

chlorpromazine, etc

●  Caffeine is metabolized through 1A2 ●  Check for medication side effects or relapse to mental

illness with changes in smoking status ●  Nicotine does not change medication blood levels (2D6) ●  NRT does not affect medication blood levels

Rationale Nicotine Replacement Plan

● Each cigarette contains about 13 mgs nicotine ! About 1 – 3 mgs of nicotine are absorbed per cigarette

● SMI tend to absorb the 2 – 3 mgs nicotine per cigarette ! Higher CO and cotinine levels than expected

● Consider NRT dosing implications ● Example: 3 packs per day = 20 cigarettes times

2 mgs per cigarette times 3 packs per day = 120 mgs nicotine

49

Personalized Feedback Matters:

● Carbon monoxide meter score and feedback ! Big impact on patients ! Short and long term benefits to

quit ● Yearly cost of cigarettes ● Medical conditions affected by

tobacco ● Links with other substance

abuse and relapses Steinberg ML, Ziedonis DM, et al. Journal of Consulting and Clinical Psychology. 2004;72(4):723-728. No PMID.

Community Resources

● Quit lines (phone) ! 1-800-QUIT-NOW

● Online (internet / apps) ! www.becomeanex.org ! www.quitnet.com ! www.ffsonline.org

● Local treatment groups ● Nicotine Anonymous

! In person, telephone, and internet meetings

Tobacco Two-Minutes: Ask, Advise, and Refer Model

● Ask about tobacco use ! Motivational level: Are you interested to quit?

● Advise (use handout visual aide) ! Lower motivated – ICR or Pro / Con (listen), brief

personalized feedback and handout ! Higher motivated – discuss med options and

psychosocial treatments with handout ● Refer

! Community resources (phone, internet, local) ! Handout – discussion issues with doctor, list of med

options, and community resources

Learning

About

Healthy

Living TOBACCO AND YOU

Jill Williams, MD Douglas Ziedonis, MD, MPH

Nancy Speelman, CSW, CADC, CMS Betty Vreeland, MSN, APRN, NPC, BC

Michelle R. Zechner, LSW Raquel Rahim, APRN

Erin L. O’Hea, PhD

Clinical Connections

● Cravings are a new diagnostic criteria in DSM-5 ● When screening patients for substance-

use consider evidence-based assessment tools ● Develop a treatment plan with the patient

that includes the discussion of medications, psychosocial interventions, community resources and online tools

#CHAIR2014

Questions & Answers

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Reference Slides

Buprenorphine

● Partial opiate receptor agonist ● Combination tablet 4:1 (bup/naloxone) ● Sublingual administration ● High affinity and slow dissociation ● Dosage ! Day 1, bup/nal 4-8 mg/1 mg day ! Day 2, bup/nal 8-12 mg/2 mg day ! Day 3, start discontinuation

PI for buprenorphine. Drugs@FDA Website.http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021431s015lbl.pdf. 2014

Buprenorphine

● 12-16 mg/day is most common dose, 8-32 is usual range

● A ceiling effect on opioid activity, including respiratory depression

● Result = likelihood of death from buprenorphine overdose markedly diminished

● Advantage over naltrexone: has mild agonist effects; patient does not have to be detoxified to begin treatment

PI for buprenorphine. Drugs@FDA Website.http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021431s015lbl.pdf. 2014

Buprenorphine Common Side Effects

● Cardiovascular: vasodilatation (9.3%) ● Dermatologic: sweating symptom (14%) ● Gastrointestinal: abdominal pain (11.2%),

constipation (12.1%), nausea (15%), vomiting (7.5%) ● Neurologic: headache (36.4%),

insomnia (14%) ● Other: pain (22.4%) PI for buprenorphine. Drugs@FDA Website.http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021431s015lbl.pdf. 2014

Buprenorphine Serious Side Effects

● Hepatic: hepatitis ● Immunologic: anaphylaxis ● Respiratory: respiratory depression ● Other: drug dependence, drug withdrawal

(25.2%)

PI for buprenorphine. Drugs@FDA Website.http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021431s015lbl.pdf. 2014

Abuse Potential

● Has been abused in the injectable form in Scotland, Australia, France, India where has been used for analgesia and dependence treatment ● Because it is a partial agonist with weaker

opioid-like effects, abuse potential is less than heroin and other full mu agonists

PI for buprenorphine. Drugs@FDA Website.http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021431s015lbl.pdf. 2014