understanding drug abuse and addiction...•suburban/rural •users start with snorting ‐iv within...
TRANSCRIPT
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Understanding Drug Abuse and AddictionSteve Hanson - Associate CommissionerNYS OASAS
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Basic Questions
•Why do people do drugs?
•Why can’t/ won’t some people stop?
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Realities
1. People like Drugs.2. We all like things faster and easier.
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Drive to Get High
Some people will seek any means to alter their state of consciousness
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Neurotransmitter Action
ReuptakeRelease of NT
Receptor
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How Drugs Work
• Interact with neurochemistry•Results:
•Feel Good – Euphoria/reward•Feel Better – reduce negative feelings
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Addiction is a Brain Disease
Prolonged Use Changes the brain in Fundamental and Long Lasting Ways
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Brain Changes
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methamphetaminemarijuanaecstasyopiumetc.
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Food
00
5050
100100
150150
200200
00 6060 120120 180180Time (min)Time (min)
% of B
asal DA Outpu
t% of B
asal DA Outpu
t
NAc shellNAc shell
EmptyEmptyBoxBox FeedingFeeding
Source: Di Chiara et al.Source: Di Chiara et al.
FOODFOOD
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Sex
100100
150150
200200
DA Con
centratio
n (%
Baseline)
DA Con
centratio
n (%
Baseline)
MountsMountsIntromissionsIntromissionsEjaculationsEjaculations
1515
00
55
1010
Copulation FrequencyCopulation Frequency
SampleNumberSampleNumber
11 22 33 44 55 66 77 88 99 10101111121213131414151516161717
ScrScrScrScrBasBasFemale 1 PresentFemale 1 Present
ScrScrFemale 2 PresentFemale 2 Present
ScrScr
Source: Fiorino and PhillipsSource: Fiorino and Phillips
SEXSEX
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Nicotine
00
100100
150150
200200
250250
00 11 22 3 hr3 hr
Time After NicotineTime After Nicotine% of B
asal Relea
se% of B
asal Relea
se AccumbensAccumbensCaudateCaudate
NICOTINENICOTINE
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Alcohol
100
150
200
250
0 1 2 3 4hrTime After Ethanol
% of B
asal Relea
se
0.250.512.5
Accumbens
0
Dose (g/kg ip)
Alcohol
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00
100100
200200
300300
400400
00 11 22 33 44 5 hr5 hrTime After CocaineTime After Cocaine
% o
f Bas
al R
elea
se%
of B
asal
Rel
ease DADA
DOPACDOPACHVAHVA
AccumbensAccumbensCOCAINECOCAINE
Cocaine
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00
100100
150150
200200
250250
00 11 22 33 44 5hr5hrTime After MorphineTime After Morphine
% o
f Bas
al R
elea
se%
of B
asal
Rel
ease
AccumbensAccumbens
0.50.51.01.02.52.51010
Dose (mg/kg)Dose (mg/kg)
MORPHINEMORPHINE
Source: Di Chiara and Imperato
Heroin
Morphine
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Source: Di Chiara and Imperato
00100100200200300300400400500500600600700700800800900900
1000100011001100
00 11 22 33 44 5 hr5 hr
Time After AmphetamineTime After Amphetamine%
of B
asal
Rel
ease
% o
f Bas
al R
elea
se
DADADOPACDOPACHVAHVA
AccumbensAccumbens METHAMPHETAMINEMETHAMPHETAMINEMethamphetamine
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Behavior Pathways•Rewarding behaviors can become routine• “Subconscious” control of the behavior•Difficult to extinguish behaviors because people are not always aware when they are initiated.
•Resistant to change
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Circuits Involved In Drug Abuse and Addiction
GOSTOP
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Go & Stop
• Craving elicits Go!!• Powerful • Activity in limbic system not frontal cortex • Feeling/reacting vs. thinking/planning• Thinking initiates Stop!!• Addicts have “bad brakes” – Stop!• Hard to stop this fast moving car.
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AMYGDALAR CONNECTIVITY during brief .5 sec Cocaine Cues
Drug 2 amyg conx (n=7)
Placebo
Baclofen
Source: Childress et al
Baclofen blunts AMYGDALAR CONNECTIVITY
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Chemical Dependency
•Chronic Disease Prone to Relapse•Requires significant behavior changes•Similar to Heart Disease, Diabetes, Asthma, Gingivitis,etc.
•Similar treatment “success”
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Drug Types• Stimulants: Cocaine, Caffeine, Methamphetamine• Depressants: Alcohol, Barbiturates, Anti‐Anxietals• Pain Relief: Opioids, Aspirin, Ibuprofen• Hallucinogens: LSD, Ecstasy, Bath Salts• Cannibinoids: Marijuana, Synthetics
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Cocaine
•Natural Stimulant from South America•Main Effects:
• Euphoria• Fight/Flight
• Snorted, Smoked, Injected, Other Mucosal Absorption
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Snorted - onset 2 mins.
Smoked - onset 5-12 seconds30-40 mins
1 hour15 mins
5 mins
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Dose Response
DOSE
EFFECT
S
Euphoria
Psychosis
Paranoia
AnxietyEnergized
MetabolicCrisis
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Animal Studies• Primates will ignore food and water in order to get cocaine – to the point of death by starvation/dehydration
• Given unlimited access to cocaine, animals will quickly die from cocaine related deaths.
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Stopping Cocaine Use
•Anhedonia ‐ Dopamine depletion•Craving ‐ intense craving for drug
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Methamphetamine
• Synthetic stimulant – Amphetamine family• Main Effects 8‐12 hours from single dose:
• Euphoria• Energy
• Snorted, smoked, injected
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Methamphetamine
DOPAMINE DOPAMINE
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Meth ‐ Signs of Abuse
•Rapid weight loss•Nervous energy•No “need” for sleep•Aggressive• Excited talk• “Meth mouth”
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Meth ‐ Signs of Withdrawal
• long crash•apathy•depression• fatigue
•anxiety•suicidal ideation
•cravings
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Alcohol•Most popular drug of abuse•Probably the most physically toxic of drugs
•Damages almost every organ in the body• Easy access, adults use, advertising, relatively inexpensive.
• THE DRUG for Youth
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Action
•Dopamine – excitement & reward•Serotonin – feel – “normal”•GABA – lowers anxiety•Endorphins – pain relief, reward, craving
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Benzodiazepine Family• Anti‐Anxiety: Valium, Xanax• Sleeping Aids: Ambien, Lunesta• Can produce dependency• Long withdrawal periods.
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Heroin/Opioids
142Americans
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3/17/2018 38
Source: CDC
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NY had 20.4% increase
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OpioidsNatural Opiates
Derived from raw opium• Morphine• Codeine
Semi‐syntheticsModified Natural
• Heroin• Vicodin
Synthetics• Fentanyl• Demerol• Methadone
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Heroin
•Heroin more potent ‐60‐80% ‐ <10% in ‘70’s• Younger age group – 18‐24 y.o. and younger• Suburban/Rural•Users start with snorting ‐ IV within 12 months•Withdrawal painful ‐ not deadly• Lots of Relapse
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Heroin
Effects• Analgesia ‐ change in pain perception
• Euphoria ‐ Intense• Sedation ‐ “on the nod”• Respiratory Depression• Cough Suppression• Nausea/vomiting• Constipation
Withdrawal• Pain• Depression• Alert• Rapid Breathing• Coughing• Nausea/Vomiting• Diarrhea• 3‐5 days
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Addiction/Dependency
• Opioids trigger reward system – euphoria – leads to continued use –addiction
• Withdrawal symptoms are significant – regular use to avoid withdrawal ‐ dependence
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Heroin usage patterns• Highly addictive and dependence producing• Significant tolerance up to 35X • Increased cost• Tolerance management (Tx, jail, etc.)• Mixing with other opiates and other drugs (speedballing/cocaine)
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Prescription Opiates
•OxyContin •Vicodin•Hysingla ER
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Overdose Reversal Kits
• Kits can save lives• Over 90,000 trained in NY• 2,900 known reversals• Available Over the Counter at pharmacies
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Two “Types” of Rx Drug Abusers
• The Drug Abuser who likes Rx drugs.
• Frequently use other drugs (cocaine, alcohol, heroin, other non‐Rx drugs)
• Fits the “model” of a drug abuser.• “addicted” to high
• The Patient who becomes dependent on their medication
• Infrequent use of other substances – unless can’t get Rx.
• Don’t fit “model” of drug user –age, other behaviors.
• “dependent” on the drug
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Marijuana
•Used since 2,700 BC•More potent today (5‐10X) than ‘70’s•Kids starting younger• Eliminates boredom, focus concentration, lowered anxiety, euphoric, increased appetite.
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Butane Hash Oil• Newest trend – aka “Dabs”
• THC extracted from MJ with butane
• 30‐80% THC• Dangerous
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Spice/K2 and Synthetic Cannabinoids
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Preparation of the “Incense”:Botanicals are sprayed with liquid preparations of:
• HU‐210• HU‐211• CP 47,497• JWH‐018• JWH‐073
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Origins of Synthetic Cannabinoids
• HU‐210 & HU‐211 ‐ synthesized at Hebrew University, Israel in 1988. HU‐210 is an anti‐inflammatory; HU‐211 as an anesthetic
• CP 47,497 ‐ developed by Pfizer in 1980 as an analgesic• JWH‐018 & JWH‐073 ‐ synthesize by a researcher at Clemson (1995) for use in THC receptor research ‐ John W. Huffman
• more than 100 different synthetic cannabinoids have been created
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Similar to THC, but…
•Psychotic episodes•Herbal incense blends are harsher to inhale
• Increased restlessness & aggressive behavior
•Doesn’t mix well with alcohol (hangovers)
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Bath Salts:• Ivory Wave• Ivory Pure• Ivory Coast• Purple Wave• Vanilla Sky
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What’s in Bath Salts?:
• Methylenedioxypyrovalerone (MDPV) is a psychoactive drug with stimulant properties
• MDPV has four times the potency of Ritalin• MDPV ‐ no history of FDA approved medical use
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Pharmacological Effects of “Bath Salts”:• increase heart rate & blood pressure• pupil dilation • hyperactivity, arousal & over stimulation• increased energy & motivation• euphoria ‐ agitation • dizziness• nausea• breathing difficulties• diminished perception of the requirement for food and sleep
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MDMA/Molly/XTC• Club drugs – produce feelings of belongingness, warmth and affection
• Intense euphoric high• Provide energy for dancing – raves• Less hallucinogenic• Dangers – teeth grinding (pacifiers)• Hyperthermia/dehydration• Hyponatremia (low salt) water intoxication – can be lethal
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Gabapentin (Neurontin)
• Used to treat epilepsy, nerve paint (herpes/shingles), restless leg, anxiety, alcohol withdrawal
• Growing misuse• Large doses produce euphoria• Can be fatal overdose – no antidote• Showing up with heroin/opioid users – possible “cutting” agent• Not tested for
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Addiction is like…
• The dog does not want to let go of the bone (addiction/ denial).
• It gets excited when it thinks its going to get its bone (craving)
• It always wants more bones (loss of control)
• Dogs live in the moment…no planning
A dog with a bone
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What Boomer is Thinking
What can I getaway with?They won’t test me
for another week.
Try the second‐hand smoke
excuse.We can talk our way out of this.
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Treatment is like…
• You teach the dog’s owner to control the dog.
• You develop a variety of tools (relapse prevention) to help the dog be obedient.
• Some dogs are harder to train.
Obedience School for the Dog
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Early Recovery Issues
• Loss of lifestyle• Loss of Coping Strategy•Withdrawal•Cognitive deficits related to early abstinence
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Cognitive Deficits
• Memory problems ‐ short term loss
• Difficulty with abstractions
• Difficulty with impulse control
• Similar performance to those with brain damage ‐Improves.
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The EndThanks
In Memory of Boomer