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