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#CHAIR2014
Sponsored by
September 11 – 13, 2014 | Westin Tampa Harbour Island
CHAIR SUMMIT7TH ANNUAL
Master Class for Neuroscience Professional Development
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#CHAIR2014
Douglas M. Ziedonis, MD, MPH University of Massachusetts Medical School UMass Memorial Health Care Worcester, MA
Substance and Alcohol Abuse
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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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#CHAIR2014
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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#CHAIR2014
Assess emerging substance-use problems, including tobacco-related products, club drugs, etc
Learning Objective 2
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#CHAIR2014
Develop a treatment plan and integrate pharmacotherapy, psychosocial treatments, and community resources in to the management of the patient with SUD
Learning Objective 3
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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.
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DSM-5 Criteria for Substance Use Disorders: Recommendations & Rationale
Hasin DS, et al. Am J Psychiatry. 2013;170(8):834-851. PMID: 23903334
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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.
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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.
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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.
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Garavan H, et al. Am J Psychiatry. 2000;157(11):1789-1798. PMID: 11058476.
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Cocaine Film Erotic Film
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Cocaine Craving Population (Cocaine Users, Controls) x Film (Cocaine, Erotic)
Cocaine Users
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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.
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Emerging Products, Substances and Resources
● Tobacco and nicotine ● Prescription drugs ● Club drugs ● Combinations ● Resource for updates on emerging
products - www.erowid.org
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Emerging Tobacco Products: Smokeless Tobacco Products
Electronic Cigarettes (E-Cigs)
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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
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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
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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
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Emerging Tobacco Products
● Hookahs and water pipes ● Little cigars
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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
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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
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Emerging Tobacco Products: Smokeless Tobacco Products ● Dissolvables
Orbs Lozenges
Strips Sticks
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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
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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
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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.
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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
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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.
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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
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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
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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.
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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
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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
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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
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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.
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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
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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.
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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
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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
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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
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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.
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Medications for Cocaine or Amphetamine Dependence
● Detoxification: ! Symptom relief
● Protracted abstinence: ! None are FDA approved
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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.
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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%
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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
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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.
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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
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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
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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.
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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
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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
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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
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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
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#CHAIR2014
Questions & Answers
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#CHAIR2014
Reference Slides
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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
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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
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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
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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
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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