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Nzinga Harrison, M.D.Senior Vice President for East Coast OperationsMedical Director
WHAT’S NEW UPDATE: ADDICTIONSDECEMBER 2012
UPDATES General Diagnostic Biological Psychological Social
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Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations... Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
American Society of Addiction Medicine. April 19, 2011
TIP 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders
◦ Equips clinicians with practical guidance and tools for treating chronic pain in adults with a history of substance abuse. Discusses chronic pain management, including treatment with opioids, and offers information about substance abuse assessments and referrals.
http://store.samhsa.gov/shin/content//SMA12-4671/SMA12-4671.pdf
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Slated for publication in May 2013 Category Change◦ Substance-Related Disorders becomes Substance
Use and Addictive Disorders
Gambling Disorder moved from Impulse Control Disorders NOS to this category
Disorders reorganized according to substance rather than diagnosis
Section III: Conditions that require further research◦ Neurobehavioral Disorder Associated With Prenatal
Alcohol Exposure◦ Caffeine Use Disorder◦ Internet Use Disorder
Substance Abuse and Dependence combined into one disorder: Substance Use Disorder with◦ Updated Severity Specifiers◦ Updated Remission Specifiers
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A. A problematic pattern of alcohol use leading to clinically significant impairment or distress.B. Two (or more) of the following occurring within a 12-month period:
1. Alcohol is often taken in larger amounts or over a longer period than was intended2. There is a persistent desire or unsuccessful effort to cut down or control alcohol use3. A great deal of time is spent in activities necessary to obtain alcohol, use the substance, or recover
from its effects4. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home
(e.g., repeated absences or poor work performance related to alcohol use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
5. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
6. Important social, occupational, or recreational activities are given up or reduced because of alcohol use7. Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile
or operating a machine when impaired by substance use8. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by the substance9. Tolerance, as defined by either or both of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effectb. Markedly diminished effect with continued use of the same amount of the substance
10. Withdrawal, as manifested by either of the following:a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for
Withdrawal)b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
11. Craving or a strong desire or urge to use alcohol
Severity SpecifiersThe Severity of each Substance Use Disorder is based on: - 0 criteria or 1 criterion: No diagnosis- 2-3 criteria: Mild Substance Use Disorder- 4-5 criteria: Moderate Substance Use Disorder- 6 or more criteria: Severe Substance Use Disorder
Remission SpecifiersEarly Remission. This specifier is used if, for at least 3 months, but for less than 12
months, the individual does not meet any of the criteria 1-10 for a Substance Use Disorder (i.e. none of the criteria except for Criterion 11, “Craving or a strong desire or urge to use a specific substance”).
Sustained Remission. This specifier is used if none of the criteria 1-10 for a Substance Use Disorder have been met at any time during a period of 12 months or longer (i.e. none of the criteria met except for Criterion 11, “Craving or a strong desire or urge to use a specific substance”).
In a Controlled Environment. This additional specifier is used if the individual is in an environment where access to alcohol and controlled substances is restricted, and no criteria for a Substance Use Disorder have been met. Examples of these environments are closely supervised and substance-free jails, therapeutic communities, and locked hospital units.
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DSM-IV TR Diagnosis:Alcohol Dependence in early, full remission
in a controlled environment
DSM-IV TR Diagnosis:Alcohol Use Disorder, severe in early
remission in a controlled environment
Treatment approach used in all areas of medicine
Considers the biological, psychological and social factors that affect a person’s health
A multidisciplinary approach that includes medical professionals, social workers, allied health workers, families, communities, YOU
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VIVITROL◦ Alcohol Dependence◦ Opioid Dependence
CHANTIX◦ Nicotine Dependence
VIVITROL FDA Indications◦ Alcohol Dependence◦ Opioid Dependence
Dosing◦ 380mg IM Q4 weeks
BLACK BOX◦ Hepatitis in excessive dosing
Monitoring◦ LFTs, Pregnancy Class C, Suicidality
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CHANTIX FDA Indications◦ Nicotine Dependence
Dosing◦ Initial treatment 12 weeks, may repeat◦ Quit smoking 8-35 days after first dose
BLACK BOX◦ Neuropsychiatric Symptoms and Suicidality
Monitoring◦ Baseline Creatinine, s/sx Depression
Current Medications with other FDA Indications being studied for Cocaine Dependence
www.clinicaltrials.gov
•Risperdal Consta•Zonisamide•Doxasozin•Modafinil•Cabergoline•Adderall•Topiramate
•Progesterone•Pramipexole•Quetiapine•Vigabatrin•D-Serine•Fluoxetine
◦ Quetiapine◦ Lofexidine◦ Naltrexone◦ Baclofen◦ Nabilone◦ Aprepitant◦ Vilazodone◦ Nefazodone
◦ Buproprion◦ Dronabinol◦ Buspar◦ Clonidine◦ Gabapentin◦ N-acetylcysteine◦ Fluoxetine
www.clinicaltrials.gov
•Current Medications with other FDA Indications being studied for Cannabis Dependence
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History of Anti-Addiction vaccines starts nearly 40 years ago with Opiate Vaccines
Advent of Methadone and Naltrexone pushed it to the background
Idea revived with epidemic rise in stimulant addiction
Conjugate vaccines exist for cocaine and nicotine
Vaccines in development for methamphetamine and opiates
Successful clinical trials Many patients do not produce a sufficient
antibody response Those patients who do produce a response
have excellent abstinence rates
COCAINE VACCINE: TA-CD◦ Anti-cocaine monoclonal antibody◦ Antibodies sequester cocaine and
retard its ability to get into the CNS◦ Enzymes in blood vessel metabolize
cocaine
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COCAINE VACCINE: TA-CD◦ Anti-cocaine monoclonal antibody◦ Antibodies sequester cocaine and
retard its ability to get into the CNS◦ Enzymes in blood vessel metabolize
cocaine
COCAINE VACCINE: TA-CD◦ Phase I and Phase 2A studies completed
by 2005◦ Multisite Phase2B studies ongoing◦ On-track to be first FDA approved
addiction vaccine
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COCAINE VACCINE: TA-CD Will likely be recommended in the
context of a treatment program to improve compliance
Vaccine doses at 0, 2, 4, 8, 12 weeks Booster shot at 6, 9, 12, 15, 18, 21,
24 months
VOLUME 91 NUMBER 1 | January 2012 | www.nature.com/cpt
NICOTINE VACCINE Development is of great interest to
pharmaceutical industry Three pharmaceutical companies have
moved vaccines forward to clinical trials◦ UK, Switzerland◦ GlaxoSmithKline
NICOTINE VACCINE GlaxoSmithKline vaccine is most advanced:
NicVAX 5 successful Phase I/II trials involving more
than 475 subjects Demonstrated immunogenic, tolerable,
correlation between antibody level, smoking cessation and abstinence at 12 months
Requires multiple doses
VOLUME 91 NUMBER 1 | January 2012 | www.nature.com/cpt
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METHAMPHETAMINE VACCINE In Pre-clinical development Development has been difficult
OPIATE VACCINE Less necessary given naltrexone,
methadone Does not cover synthetic narcotics which
are the fastest growing segment
VOLUME 91 NUMBER 1 | January 2012 | www.nature.com/cpt
Prefrontal Cortex Stimulation as Treatment for Crack-cocaine Addiction
repeated transcranial Direct Current Stimulation over the left dorsolateral prefrontal cortex in the treatment of crack-cocaine addiction
www.clinicaltrials.gov
Enzymatic therapies aimed at accelerating the metabolism of Cocaine◦ Butyrylcholinesterase ◦ Cocaine Esterase◦ Cocaine Hydrolase
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re-engineering of human plasma butyrylcholinesterase has led to enzymes that destroy cocaine so efficiently that they prevent or interrupt drug actions in the CNS even though confined to the blood stream
gene-transfer technology has made it possible to deliver such enzymes by endogenous gene transduction at high levels for periods of a year or longer after a single treatment.
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SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders.
Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.
Since 2003, SAMHSA has funded◦ seventeen (17) Medical Residency Cooperative
Agreements◦ fifteen (15) State Cooperative Agreements◦ twelve (12) Targeted Capacity Expansion Campus
Screening and Brief Intervention (SBI) Grants.
MBRP offers skills in cognitive-behavioral relapse prevention integrated with mindfulness meditation
Those randomized to MBRP, as compared with those in a control group, demonstrated significantly lower rates of substance use and greater decreases in craving following treatment.
Individuals in MBRP did not report increased craving or substance use in response to negative affect.
Psychol Addict Behav. 2012 Jul 9. [Epub ahead of print]
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Colorado, Washington Become First States to Legalize Recreational Marijuana
Colorado's Proposition 64 to the state's constitution makes it legal for anyone over the age of 21 to possess marijuana and for businesses to sell it.
A similar measure on the ballot in Washington State legalizes small amounts of marijuana for people over 21.
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The number of text messaging interventions designed to initiate and support behavioral health changes have been steadily increasing over the past 5 years.
Messaging interventions can be tailored and adapted to an individual's needs in their natural.
Psychol Addict Behav. 2012 Sep 10. [Epub ahead of print]
Fifty individuals enrolled in intensive outpatient substance abuse treatment completed an assessment battery relating to preferred logistics of mobile interventions, behavior change strategies, and types of messages they thought would be most helpful to them at different time points.
Psychol Addict Behav. 2012 Sep 10. [Epub ahead of print]
Results ◦ 98% participants were potentially interested in
using text messaging as a continuing care strategy. ◦ Individuals tended to prefer benefit driven over
consequence driven messages◦ Differences in the perceived benefits of change
among individuals predicted message preference.
Psychol Addict Behav. 2012 Sep 10. [Epub ahead of print]
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“Addiction”: 256 hits in the App Store “Addiction”: 199 hits in Google Play◦ Meeting Finders◦ Online Support◦ Recovery Trackers◦ Symptom Trackers◦ Etc.
Addiction as a treatment field is changing◦ More biological interventions◦ Gene Therapy Developments◦ Medication developments slow
DSM-V will change diagnostic process and nomenclature
Developments are occurring in Biological, Psychological and Social realms
Biological interventions focus on Nicotine and Cocaine Dependence with immunizations at the forefront of development
Psychological Interventions continue to center around whole health interventions, mindfulness gaining traction
Social Interaction reflect the changing culture of communication including texts and apps
