The Science Behind the Disease of Addiction and How It Binds Us All Together Virginia Summer...
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The Science Behind the Disease of Addiction and How It Binds Us All Together Virginia Summer Institute on Addiction Studies July 14, 2015 Mary G. McMasters,
The Science Behind the Disease of Addiction and How It Binds Us
All Together Virginia Summer Institute on Addiction Studies July
14, 2015 Mary G. McMasters, MD, FASAM
Cheat Sheet cont Buprenorphine- mixed opioid
agonist/antagonist, structure- ultra synthetic opioid (Imodium is
also an ultra synthetic opioid) Naloxone- only active if taken IV
(not by mouth of if snorted), Full opioid antagonist Suboxone,
Bunavail and Zubsolv= Buprenorphine + Naloxone Subutex=
Buprenorphine
Slide 5
CONTACT INFORMATION 540-688-2426 [email protected] 9
Pinnacle, Ste 105, Fishersville, VA 22939 Physician Clinical
Support System Mentor, SAMHSA, www.PCSSmentor.org
Slide 6
I have disclosed that I do not have a financial relationship or
interest with any proprietary entity producing healthcare goods or
services in conjunction with this conference.
Slide 7
Mary G. McMasters, MD, FASAM Board Certified Addiction Medicine
Appointee, Gov. McAuliffe, Task Force on Prescription Drug Abuse
and Heroin Hospice/Palliative Care Physician Co-Medical Director
Project REMOTE Expert Witness USDOJ Adjunct Instructor DEA FELLOW,
AMERICAN SOCIETY OF ADDICTION MEDICINE Old Country
Addictionologist
Slide 8
PLEASE STOP ME WITH QUESTIONS
Slide 9
The United States of Drugs
Slide 10
The Cost of Prescription Drug Abuse John Deskins, Bureau
Business and Economy, WVU Presentation Appalachian Drug Summit,
USDOJ, 2013, Johnson City, TN 2013- estimated 62 billion lost 4%
drug abuse tx 2% medical complications 15% criminal justice costs
including victims 79% lost productivity Premature death
Unemployment Subemployment Does NOT account for multipliers
Slide 11
John Deskins cont Per year: WV- entire state and local
government spending on police KY- entire amount spent on elementary
and secondary education TN- entire amount spent on highways
annually
Slide 12
PP=physical tolerance, with- drawal Higher Brain A A=Addiction
TERMINOLOGY!!!!!
Slide 13
Physical Adaptations Tolerance and Dependence PHYSICAL
Physiological adjustment to MANY medications Anti-depressants
Anti-hypertensives NOT the same thing as the substance misuse
disorders (diversion, substance abuse and addiction)
Slide 14
Physical Adaptations Tolerance: it takes more of a substance
(therapeutic or non-therapeutic) to achieve a goal (therapeutic or
non-therapeutic) Ex: A patient needs more beta blocker (an anti-
hypertensive medication) to control their blood pressure A regular
user of Oxycontin can tolerate a dose which would make a non-user
stop breathing. TOLERANCE NORMALLY HAS A CEILING!!!!!!!!
Slide 15
Physical Adaptations withdrawal syndrome Physical Dependence:
the sudden cessation of a substance to which the body has become
accustomed (therapeutic or non-therapeutic) results in a withdrawal
syndrome Ex: A physician stops a beta blocker abruptly without
weaning it and the patient feels panicky, has high blood pressure
and a fast heart rate An opiate addict cant get his/her fix and
becomes nauseated, shaky and sick. SOLUTION: WEAN SLOWLY!!!!!
Slide 16
Opioid Withdrawal Can be miserable for some people Some people
may have none to little even with cold turkey weans. Usually not
life threatening Repeated HARD, cold turkey detox episodes leads to
MORE substance abuse, not less Risks and Benefits
Slide 17
Detox -Detox = weaning - Detoxification only treats the
physical dependence, NOT the Addiction - Patients who are
detoxified lose their tolerance to respiratory depression -When
they resume substance use, they are likely to die -FACTOID:
Harrison Narcotics Act 1914, doctors allowed distribution "in the
course of his professional practice only." This clause was
interpreted after 1917 to mean that a doctor could not prescribe
opiates to an addict *Heit HA; Dear DEA, Pain Medicine Vol 5 #3,
2004, 303-308
HIGHER BRAIN PROBLEMS SUBSTANCE ABUSE the substance use is
continued despite knowledge of having a persistent or recurrent
physical or psychological (or social or occupational) problem that
is likely to have been caused or exacerbated by the substance.
Slide 20
HIGHER BRAIN DISEASE: ADDICTION the substance use is continued
despite knowledge of having a persistent or recurrent physical or
psychological (or social or occupational) problem that is likely to
have been caused or exacerbated by the substance. persistent desire
or unsuccessful efforts to cut down or control substance use.
Slide 21
Addiction Repeatedly doing something which is BAD for you (not
just bad) Cannot stop doing it without help CHRONIC BRAIN DISEASE
with reproducible pathophysiology (anatomical, chemical, genetic)
IT ALL COMES DOWN TO FUNCTIONING!!!!!!!!
Slide 22
NOT ADDICTION IS NOT SUBSTANCE SPECIFIC Preferences Due to SIDE
EFFECTS VERY generally: Externalizers (outgoing, hyperactive, very
social) prefer downers Internalizers (depressed, shy) prefer uppers
ADDICTION HAS NO BRAND LOYALTY!
Slide 23
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HOW DO YOU KNOW IF A RAT HAS ADDICTION?
Slide 25
Food, Water, Procreating, Taking Care of Young SUBSTANCE
Slide 26
Food, Water, Reproducing, taking Care of Young SUBSTANCE
Slide 27
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HOW DO YOU KNOW IF A HUMAN HAS ADDICTION? WILL CHOOSE THE
SUBSTANCE INSTEAD OF: TAKING CARE OF THEMSELVES, THEIR FAMILIES,
THEIR RELATIONSHIPS AND THEIR LIVES CANT STOP WITHOUT HELP
HOW DO YOU MAKE AN ADDICTED RAT? (OR HUMAN?) GENETIC
PREDISPOSITION PLUS EXPOSURE TO SUBSTANCE
Slide 31
PART 1: GENETIC PREDISPOSITION SOME RATS/HUMANS GET A LITTLE
SOME RATS/HUMANS GET A LOT SOME RATS/HUMANS HAVE NONE!!!!
SCIENTISTS CAN MOVE THE GENES AROUND (IN RATS, NOT HUMANS-
YET)
Slide 32
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PART 2: EXPOSURE TO SUBSTANCES WHAT MAKES A SUBSTANCE
ADDICTIVE? ELEVATES DOPAMINE IN THE FOREBRAIN ABOVE LEVELS NORMALLY
SEEN IN NATURE A. FAST B. HIGH THE FASTER AND THE HIGHER, THE MORE
ADDICTIVE A SUBSTANCE IS
Slide 35
Slide 36
How Quickly can you get chemicals into the brain? Swallowing-
VERY Slow Taking on an Empty Stomach- Slow Inhale- Fast Inject into
Blood- VERY Fast
Slide 37
Well, This Is One Way Around That Pesky Slow Release Abused
Oxycontin
Slide 38
Once Inside the Brain, What do Substances of Abuse DO? Trigger
the Natural Reward System Increase Dopamine in the Forebrain The
FASTER The HIGHER THE MORE ADDICTIVE MANY more things than Abused
Substances can trigger this system
Slide 39
Increase in dopamine Rate of increase, fast to slow Heroin,
cocaine, IV Dilaudid, Nicotine, Snorted/Injected Oxycontin (old
formulation), Xanax Percocet, Immediate Release Morphine, Higher
Proof Liquor, non-injected Oxycontin, Vicodin Abused Methadone,
Abused Buprenorphine, Lower Proof Alcohol, Marijuana Methadone,
Buprenorphine taken as directed
Slide 40
Street Value 100 Vicodin $500-$800 100 Xanax 2mg $1,000 4
Fentanyl patches 100ug $400 100 Dilaudid 8mg $8-10,000 100
Oxycontin 80mg (old formulation) $8- 16,000 Methadone 1$ per
milligram Percocet 10mg $32/pill (8/25/11 personal report) * Beard,
J Tobias, Coke is the Real Thing; Fifty bucks and youre in with
Charlottesvilles favorite powder, CVILLE CHARLOTTESVILLE NEWS &
ARTS, 2/11/2008
Slide 41
Non-controlled substances with street value Muscle Relaxants
Neurontin Remeron HIV medications Prednisone ULTRAM!!!!!!!!! (Now
controlled) Its not about the Substance. Its about the Brain.
Slide 42
Who is Using??? PATIENT A : Cigarette smoker? PATIENT B: The
patient taking Suboxone as prescribed for the disease of Addiction?
(Remember, Using = elevating dopamine ABOVE levels normally
experienced in nature)
Slide 43
PUTTING IT ALL TOGETHER Inherited Threshold for Addiction AGE
15 10 20 25 3035 4045 Cumulative Dopamine Spikes X Y Z ADDICTION
STARTS AGE 36
Slide 44
Inherited Threshold for Addiction AGE 15 10 20 25 3035 4045
More frequent exposure X Y Z ADDICTION STARTS AGE 24 Cumulative
Dopamine Spikes Self-medicating (PTSD, abuse, underlying
psychpathology) Sociopathy Poor Parenting Social Norms
Slide 45
Inherited Threshold for Addiction AGE 15 10 20 25 3035 4045
Onset of Add iction Lower inherited threshold X Y Z Cumulative
Dopamine Spikes ADDICTION STARTS AGE 20
Slide 46
Inherited Threshold for Addiction AGE 15 10 20 25 3035 4045
Onset of Add iction X Y Z Cumulative Dopamine Spikes ADDICTION
STARTS AGE 20 Starting Substance Use Earlier decreases the
threshold
Slide 47
NO Threshold for Addiction AGE 15 10 20 25 3035 4045 Cumulative
Dopamine Spikes
Slide 48
Addiction: A Disease of Learning and Memory Steven E. Hyman,
M.D. If neurobiology is ultimately to contribute to the development
of successful treatments for drug addiction, researchers must
discover the molecular mechanisms by which drug-seeking behaviors
are consolidated into compulsive use, the mechanisms that underlie
the long persistence of relapse risk, and the mechanisms by which
drug-associated cues come to control behavior. Evidence at the
molecular, cellular, systems, behavioral, and computational levels
of analysis is converging to suggest the view that addiction
represents a pathological usurpation of the neural mechanisms of
learning and memory that under normal circumstances serve to shape
survival behaviors related to the pursuit of rewards and the cues
that predict them. The author summarizes the converging evidence in
this area and highlights key questions that remain. (Am J
Psychiatry 2005; 162:14141422) ADDICTION
Slide 49
Slide 50
Rifles
Slide 51
Shot Guns SCATTER
Slide 52
ALL Medications are Shot Guns example: Aspirin Target: Pain
control (4 hours) Thins blood (30 days) Irritates stomach
(immediate)
Slide 53
Opioids are also Shot Guns Pain control Constipation Dopamine
Spike Or Addictive Liability Or Psychoactive Properties Respiratory
Depression Tolerance to Respiratory Depression Tolerance To
Dopamine Spike
Slide 54
Changing the molecule to change the target Add an OH group,
Longer acting Add an ring, More pain relief Add an N, More
psychoactive Add an N and a chain, Doesnt cross blood brain
Barrier, constipates only Not to scale, not exact organic
compounds, for illustration Only.
Slide 55
Finally (on the subject of Organic Chemistry) TARGETS are
variable!!! i.e. Every BRAIN is different!!!
Slide 56
ADDICTIVE LIABILITY IS NOT THE SAME THING AS PAIN RELIEVING
POTENCY!!! Equals how fast/high a substance elevates dopamine in
the forebrain Equals POTENCY Low potency One dollar buys a pack of
gum Small Slow Dopamine Spike High potency One dollar buys a house
Big Fast Dopamine Spike
Slide 57
BRAINS ARE PLASTIC!!!! HOW BRAINS HEAL Repair Rewiring This is
why counseling and 12 step participation IS NOT HOCUS-POCUS!!!!!
Galanter M, Spirituality, Evidence-Based Medicine, and Alcoholic
Anonymous, Am J Psychiatry 165:12, Dec 2008
Slide 58
12 STEP PROGRAMS Addiction was not a real medical disease and
physicians cannot treat it Harrison Narcotic Act 1914 The affected
community had to come up with their own solution 12 Step Programs
developed OUTSIDE of medical science (with few exceptions) Like
many herbal remedies, there is good science behind 12 Step
Programs. We just havent figured it all out yet. Good EBM that they
are effective for the disease of Addiction
Slide 59
How To Become Richer than God The pill to cure Addiction
Addicts (and their families) are the most vulnerable population in
health care Parasites and Predators H. Westley Clarke, MD, former
Director of NIDA Bad-mouthing 12 Step Programs to influence
research subject pools. 12 Step Programs are Anonymous and dont
defend themselves.
Slide 60
12 STEP PROGRAMS Effective (Not Perfect) Accessible Lifelong
and FREE When you hear Were not a 12 Step Program. We REALLY work,
ask: Is what youre offering effective as shown via Evidence Based
Medical Science? The American Society of Addiction Medicine? Is it
accessible to EVERY patient EVERY day for the rest of his/her life?
(Dont let the critics re-define Addiction as an acute disease)
Slide 61
COUNSELING NOT OPTIONAL FOR PATIENTS ON MAAT (AND MANY OTHERS
NOT ON MAAT) NOT OPTIONAL FOR PATIENTS WITH CO-MORBID ISSUES AND A
GREAT DEAL OF SOCIAL CHAOS ESSENTIAL THAT COUNSELING WORK TO
INTEGRATE PATIENTS INTO THEIR COMMUNITY SUPPORT GROUPS Why is it so
much easier to get third party payers to reimburse for the pills
which cause the problems than for the counseling which helps to
deal with it??????
Slide 62
What Damage do substances of abuse do to Brains? Toxins and
Free Radicals Predispose to the Development of Addiction
Slide 63
Brains dont have pain receptors!!! Instead, a damaged brain
will become Depressed Anxious Unable to concentrate Unable to
coordinate movement Insomniac Abnormally aware of pain
(hyperalgesia) Less able to process and understand information Less
smart, i.e. have a decreased IQ Maturationally and developmentally
impaired These can become permanent
Slide 64
Co-Morbid Psychiatric Diagnoses It is VERY important that NO
major mental illness be diagnosed until a patient has been
substance free for a long time (in my opinion six months) Many (not
all) other psychiatric problems will go away once the brain is
given time to heal Medications for depression, anxiety, etc. are
NOT effective when other substances are in the brain
Slide 65
PAIN vs. SUFFERING PHYSICAL EMOTIONAL SPIRITUAL
Slide 66
PAIN vs. SUFFERING PHYSICAL EMOTIONAL SPIRITUAL WHOLE
PERSON
Slide 67
THERES A LOT OF SUFFERING GOING ON (AND IT ALL GOES ON IN THE
BRAIN!) (AND THERES A LOT MORE COMING.)
Slide 68
Treating Addiction Dont just Detox!!!!! Dont just Detox!!!!!
COUNSELING 12 Step meetings Others (if available and affordable)
Adjunct Medications Minority of patients
Slide 69
LEVELS OF CARE Diabetes Addiction 12 Step Participation Basic
Diabetic Teaching and Home Blood Sugar Monitoring Basic Diabetic
Teaching Plus Dietician Monitoring 12 Step Participation Plus
Addiction Specific Professional Counseling Plus Outpatient
Buprenorphine TxPlus Oral Medication Plus Insulin Plus Methadone
Clinic Inpatient, IOP
Methadone Can ONLY be obtained in a licensed methadone clinic
(for addiction) Methadone clinics are A HIGHER LEVEL OF CARE Crime
reduction, death reduction, reduction in transmission of blood
borne diseases, increased tax revenues HARM REDUCTION For the
sickest of the sickest of the sick Low doses (30-40mg/day) block
withdrawal, not cravings
Slide 72
Buprenorphine Can only be obtained from a licensed
Buprenorphine provider Should be coupled with counseling and
integration into community support groups (12 step) For the sickest
of the sick. WITH NALOXONE!!!!!!
Slide 73
BUPRENORPHINE: THE GREAT MOTIVATOR Contingent on participation
in counseling Contingent on PROGRESS towards abstinence Identifying
the substance of choice Triage substance use Dangerous Not
consistent with recovery Plan for RELAPSE A relapse isnt a relapse
isnt a relapse ASAM Placement Criteria
Slide 74
Diversion of Buprenorphine and Methadone To avoid physical
withdrawal To provide withdrawal-free periods For work Stockpile
between shipments of the good stuff Self treatment of Addiction To
get high MUST be opioid-nave < 3% endorse buprenorphine as their
substance of choice - Cicero To be diverted to pay for substance of
choice
Slide 75
End Points (but not of this presentation) Reduce death rate due
to opioids Improve functioning Abstinence??? THERE IS A LOT OF HARM
REDUCTION ON THE WAY TO ABSTINENCE. !
Slide 76
Am J Addict. 2004;13 Suppl 1:S17-28. French field experience
with buprenorphine. Auriacombe M1, Fatsas M, Dubernet J, Dauloude
JP, Tignol J. Author information Abstract In most European
countries, methadone treatment is provided to only 20-30% of opiate
abusers who need treatment due to regulations and concerns about
safety. To address this need in France, all registered medical
doctors since 1995 have been allowed to prescribe buprenorphine
(BUP) without any special education or licensing. This led to
treating approximately 65,000 patients per year with BUP, about ten
times more than with more restrictive methadone policies. French
physician compensation mechanisms, pharmacy services, and medical
insurance funding all minimized barriers to BUP treatment. About
20% of all physicians in France are using BUP to treat about half
of the estimated 150,000 problem heroin users. Daily supervised
dosing by a pharmacist for the first six months resulted in
significantly better treatment retention (80% vs 46%) and lower
heroin use. Intravenous diversion of BUP may occur in up to 20% of
BUP patients and has led to various infections and relatively rare
overdoses in combination with sedatives. Opiate overdose deaths
have declined substantially (by 79%) since BUP was introduced in
1995. Newborn opiate withdrawal in mothers treated with
buprenorphine compared to methadone was reported to be less
frequent, less severe, and of shorter duration. Although some of
the public health benefits seen during the time of buprenorphine
expansion in France might be contingent upon characteristics of the
French health and social services system, the French model raises
questions about the value of tight regulations on prescribing BUP
imposed by many countries throughout the world. PMID: 15204673
[PubMed - indexed for MEDLINE]
Slide 77
How Long? Less than 3 months: useless More than 6 months?????
Not willing to do the work Need to work through barriers to
recovery Forcing people off of methadone leads to increased death
rate Subset where buprenorphine and methadone are treating
something other than the cravings (non- defined scatter).
Slide 78
Urine Drug Screens As Organic Chemists have altered the opioid
molecule, many opioids are no longer detected by basic (natural)
opioid screens Ultra-synthetic opioids must be tested for
SEPERATELY: methadone, buprenorphine, ultram (Tramadol) Too much to
remember? YOURE RIGHT!!!!
Slide 79
ALL YOULL EVER NEED TO KNOW ABOUT URINE DRUG SCREENS!!!
1.ALWAYS call and clarify unexpected results 1.Youre paying for
this service, USE IT 2. They are very seldom WRONG 3. Youre only
responsible for doing the best you can If the patient gets by with
something this time, their good luck wont last forever
Slide 80
Medico-Legal A UDS is just another lab test HIPAA protects ALL
lab tests You need to know what the patient has in his/her system
at the time you prescribe a controlled substance Medico-Legal is a
term often used to scare prescibers and make more $ for labs
Slide 81
Which Results do you need? Sensitivity- detects True Positives
Specificity- detects True Negatives The more Sensitive a test is,
the less Specific it is (most of the time) The more Specific a test
is, the less Sensitive it is (most of the time)
Slide 82
REFERENCES DONT TAKE MY WORD FOR IT DONT TAKE ANYONES WORD FOR
IT GET THE FACTS CHECK THE REFERENCES
Slide 83
Sources of Information www.casacolumbia.org Monitoring the
Future, NIDA www.monitoringthefuture.org
www.monitoringthefuture.org www.drugabuse.gov www.samhsa.gov
www.health.org www.clubdrugs.org www.drugfreeamerica.org
www.collegedrinkingprevention.gov
www.jointogether.org/sa/news/features
Slide 84
A Few References REMS CO*RE, ER/LA Opioid REMS, Completer Slide
Deck, www.core-rems.orgwww.core-rems.org Alford, Compton, Samet;
Acute Pain Management for Patients Receiving Maintenance Methadone
or Buprenorphine Therapy; Ann Intern Med. 2006;144:127-134.
Ballantyne, LaForge; Opioid Dependence and addiction during opioid
treatment of chronic pain; Pain 1209 (2007) 235-255.
Slide 85
FREE, GOOD EDUCATION!!! http://pcssmat.org/education-
training/archived-webinars/