Understanding Drug Abuse and AddictionSteve Hanson - Associate CommissionerNYS OASAS

Basic Questions

•Why do people do drugs?

•Why can’t/ won’t some people stop?

Realities

1. People like     Drugs.2. We all like things faster and easier.

Drive to Get High

Some people will seek any means to alter their state of consciousness

Neurotransmitter Action

ReuptakeRelease of NT

Receptor

How Drugs Work

• Interact with neurochemistry•Results:

•Feel Good – Euphoria/reward•Feel Better – reduce negative feelings

Addiction is a Brain Disease

Prolonged Use Changes the brain in Fundamental and Long Lasting Ways

Brain Changes

methamphetaminemarijuanaecstasyopiumetc.

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

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

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

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

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

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

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

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

Circuits Involved In Drug Abuse and Addiction

GOSTOP

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. 

AMYGDALAR CONNECTIVITY during brief .5 sec Cocaine Cues

Drug 2 amyg conx (n=7)

Placebo

Baclofen 

Source: Childress et al

Baclofen blunts AMYGDALAR CONNECTIVITY

Chemical Dependency

•Chronic Disease Prone to Relapse•Requires significant behavior changes•Similar to Heart Disease, Diabetes, Asthma, Gingivitis,etc.

•Similar treatment “success” 

Drug Types• Stimulants: Cocaine, Caffeine, Methamphetamine• Depressants: Alcohol, Barbiturates, Anti‐Anxietals• Pain Relief: Opioids, Aspirin, Ibuprofen• Hallucinogens: LSD, Ecstasy, Bath Salts• Cannibinoids: Marijuana, Synthetics

Cocaine

•Natural Stimulant from South America•Main Effects:

• Euphoria• Fight/Flight 

• Snorted, Smoked, Injected, Other Mucosal Absorption

Snorted - onset 2 mins.

Smoked - onset 5-12 seconds30-40 mins

1 hour15 mins

5 mins

Dose Response

DOSE

EFFECT

S

Euphoria

Psychosis

Paranoia

AnxietyEnergized

MetabolicCrisis

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.

Stopping Cocaine Use

•Anhedonia ‐ Dopamine depletion•Craving ‐ intense craving for drug

Methamphetamine

• Synthetic stimulant – Amphetamine family• Main Effects 8‐12 hours from single dose:

• Euphoria• Energy

• Snorted, smoked, injected

Methamphetamine

DOPAMINE DOPAMINE

Meth ‐ Signs of Abuse

•Rapid weight loss•Nervous energy•No “need” for sleep•Aggressive• Excited talk• “Meth mouth”

Meth ‐ Signs of Withdrawal

• long crash•apathy•depression• fatigue

•anxiety•suicidal ideation

•cravings

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

Action

•Dopamine – excitement & reward•Serotonin – feel – “normal”•GABA – lowers anxiety•Endorphins – pain relief, reward, craving

Benzodiazepine Family• Anti‐Anxiety: Valium, Xanax• Sleeping Aids: Ambien, Lunesta• Can produce dependency• Long withdrawal periods.

Heroin/Opioids

142Americans

3/17/2018 38

Source: CDC

NY had 20.4% increase

OpioidsNatural Opiates

Derived from raw opium• Morphine• Codeine

Semi‐syntheticsModified Natural

• Heroin• Vicodin

Synthetics• Fentanyl• Demerol• Methadone

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

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

Addiction/Dependency

• Opioids trigger reward system – euphoria – leads to continued use –addiction

• Withdrawal symptoms are significant – regular use to avoid withdrawal ‐ dependence

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)

Prescription Opiates

•OxyContin •Vicodin•Hysingla ER

Overdose Reversal Kits

• Kits can save lives• Over 90,000 trained in NY• 2,900 known reversals• Available Over the Counter at pharmacies

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

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.

Butane Hash Oil• Newest trend – aka “Dabs”

• THC extracted from MJ with butane

• 30‐80% THC• Dangerous

Spice/K2 and Synthetic Cannabinoids

Preparation of the “Incense”:Botanicals are sprayed with liquid preparations of:

• HU‐210• HU‐211• CP 47,497• JWH‐018• JWH‐073

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

Similar to THC, but…

•Psychotic episodes•Herbal incense blends are harsher to inhale 

• Increased restlessness & aggressive behavior 

•Doesn’t mix well with alcohol (hangovers)

Bath Salts:• Ivory Wave• Ivory Pure• Ivory Coast• Purple Wave• Vanilla Sky

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

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

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

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

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

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.

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

Early Recovery Issues

• Loss of lifestyle• Loss of Coping Strategy•Withdrawal•Cognitive deficits related to early abstinence

Cognitive Deficits

• Memory problems ‐ short term loss

• Difficulty with abstractions

• Difficulty with impulse control

• Similar performance to those with brain damage ‐Improves.

The EndThanks

In Memory of Boomer