2 Definition of Addiction Compulsion: loss of controlThe user can’t not do it s/he is compelled to use.Compulsion is not rational and is not planned.Continued use despite adverse consequencesAn addict is a person who uses even though s/he knows it is causing problems.Addiction is staged based on adverse consequences.Craving: daily symptom of the diseaseThe user experiences intense psychological preoccupation with getting and using the drug.Craving is dysphoric, agitating and it feels very bad.Denial/hypofrontality: distortion of cognition caused by cravingUnder the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using.
3 Neuroadaptation, Tolerance, and Withdrawal Neuroadaptation is the brain’s response to over stimulation from drugs. Drug-specific circuits cause a mixture of sedation and stimulation or intoxication.Tolerance is the process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure neurotransmitters. In direct response to overstimulation, the brain regions decrease in sensitivity and become unresponsive (deaf) to normal levels of stimulation.In addition to pleasure circuits each drug type affects other specific circuits. Other brain pathways overstimulated by drugs also neuroadapt and become under active, directly leading to anxiety, depression, and loss of energy.Once neuroadaptation develops (tolerance), there will always be withdrawal symptoms that are the mirror image of the drug effects. Cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless, and lacking energyUnder unstimulated conditions (without drugs) there is profound interference with the ability to experience normal pleasure. When sober, the user feels anhedonia, anxiety, anger, frustration and craving. The pleasure system remains impaired for months to years, interfering with sobriety, learning, and impulse inhibition.
4 Drug-Specific Neural Dysregulation Withdrawal Withdrawal: Negative symptoms that mirror positive drug effects AND reflect neuroadaptation (tolerance).Cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless, and lacking energy.Under unstimulated conditions (without drugs) interference with the ability to experience normal pleasure is profound . When sober, the user feels anhedonia, anxiety, anger, frustration and craving.The pleasure system remains impaired for months to years, interfering with learning, impulse inhibition, and sobriety.
5 Kindling In tolerant users: Progressive nervous system arousal causing withdrawal symptoms to worsen each time drug use is discontinued.Also called withdrawal sensitization.
6 C I M Model Treatment Tolerance/Withdrawal Over-stimulation of brain pathways induces neuroadaptation, requiring the user to escalate the dose to achieve the effects formerly seen at lower doses.Whenever there is tolerance to drugs/alcohol, there will always be the appearance of negative symptoms (withdrawal) when the user is sober; these negative symptoms are the mirror image of the drugs’ effects.
7 Physical Dependence Physical Dependence Abstinence Syndrome Tolerance When the user stops the drug, physical illness results.Abstinence SyndromeName of the illness caused by withdrawal symptoms.ToleranceNeuroadaptation forces the user to increase the dose to maintain the effect of the drug.Using an inadequate dose causes withdrawal: symptoms occur when the amount used is less than the tolerance level.
8 C I M Model Treatment Causes of Craving E W M SEnvironmental cues (Triggers)immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiencesDrug Withdrawalinadequately treated or untreatedMental illness symptomsStress equals craving
9 Withdrawal Management Detoxification Use of medications to treat withdrawal symptoms.Goals:EvaluationStabilizationFoster readiness for and entry into treatmentGoals from TIP 45, Page 16
10 C I M Model Treatment Withdrawal Management Withdrawal management is the use of medications to treat drug withdrawal symptoms, sometimes called “detox.”When is withdrawal management needed?If the pulse is persistently above 90 beats per minuteIf the blood pressure is persistently above 140/90 or below 90/60If INSOMNIA interferes with functionIf ANXIETY interferes with function.If CRAVING threatens to cause relapse
11 C I M Model Treatment Withdrawal Management PRINCIPLESCalculate the dose equivalent per 24 hoursPush medications to achieve “symptom capture”Maintain Diastolic BP <90 and Pulse <90Decrease substitute medication in 10% incrementsSlow rate of taper to maintain Diastolic BP <90 and Pulse <90Tremor freeSUBSTITUTIONTAPER
17 Opiate Progression Pills to the Needle Historically, untreated dependence on prescription opiates led to a trajectory fromPills ingested orallyPills crushed and snorted or smokedHeroin snorted or smokedHeroin used intravenously
18 Overview of Buprenorphine Suboxone and Subutex Highly safe medication (acute & chronic dosing).Primary side effects: like other mu agonist opioids (e.g.,nausea, constipation) but may be less severe.No evidence of significant disruption in cognitive or psychomotor performance with buprenorphine maintenance.No evidence of organ damage with chronic dosing.Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds: Strain EC, Trhumble JG, Jara GB) CSAT. 2001Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds: Strain EC, Trhumble JG, Jara GB) CSAT. 2001
21 OPTIMUM ANALGESIC DOSE The best dose of opiate is the dose that first, best relieves pain, and second, relieves pain without sedation.
22 Special Problems in Former Opiate Addicts Persons previously addicted to opiatesHave low pain tolerance because endogenous analgesic mechanisms are impaired.Will “uncover” their previous level of opiate tolerance over weeks and require upward dosage titration over an extended time (despite years of abstinence).Require doses 2 to 4 times higher for analgesia than non-tolerant persons (due to high opiate tolerance).Need slower, symptom-driven tapers to discontinue opiates.
24 Withdrawal Management Opiate Substitution Query: time since last opiate useQuery: all opiates used in past 7 days.Calculate client's usual 24 hour opiate dose.Query: prior withdrawal experience(s).Query: other drugs used:alcoholillicit drugsprescription medicationsover-the-counter preparationsDetermine if client requires other detoxification
25 Withdrawal Management Substitution Methodology OpiatesCalculate Suboxone dose using opiate dose equivalents.Give first Suboxone dose (2 - 8 mg) when objective and clear signs of withdrawal are evident.Record Pulse, BP, and withdrawal SX on Symptom Assessment sheet.Recheck Pulse & Blood Pressure after 90 minutes.Give 1/4 of estimated daily Suboxone dose when withdrawal symptoms reappear.Give the remainder of Suboxone in divided doses every hours.
26 Withdrawal Management Completion of Substitution Phase Substitution is complete when the patient feels “normal,” and craving goes away.Persistence of insomnia, anxiety, pain, or depression indicate need for separate treatment of these symptoms (dual diagnosis).The patient is now ready for taper or for maintenance.
27 Withdrawal Management Taper Phase There are two variables in tapering:Dose: how much to taperTime: how often to taperDose reductions are adjusted so that the patient does not re-enter withdrawal. If withdrawal symptoms develop during taper, return to previous effective dose, reduce amount of taper (dose) or lengthen the (time) interval. Do not continue until symptoms subside.Monitor Pulse and Blood Pressure dailyComplete Symptom Assessment sheet daily.Adjust amount decreased and time between decreases to maintain symptom scores at 0-1
28 A 33-year follow-up of narcotics addicts .Hser YI, Hoffman, V, Grella CE, Anglin D. A 33-year follow-up of narcotics addicts. Archives of General Psychiatry. 2001;58:
29 Stimulant Effects Improve mood and confidence Increase interest/alertnessIncrease sex driveInterference with sleepIncrease anger and aggressionSuppress appetitePupils dilateIncreases heart rate & blood pressureFeverArrythmia - irregular heart beatSeizuresMethamphetamine is a long-acting central nervous system stimulant that is highly addictive. It comes in a variety of forms, and its effects vary depending on whether ingested orally, snorted, smoked or injected intravenously. Smoking or injecting methamphetamine increases the potential for addiction and its subsequent consequences because the drug is absorbed in the brain more rapidly. Although the eurphoric effects can be felt in 3-5 minutes when snorted, and ingestion is noticeable within minutes, neither compares to the immediate intense RUSH response produced when methamphetamine is smoked or injected intravenously Lasting only a few minutes this initial RUSH described as extremely pleasureable, is the result of a rapid increase in the concentration of dopamine in the brain’s reward centers.
41 Withdrawal Management Sedative-Hypnotics SubstitutionObtain seizure history.Question client regarding all sedative-hypnotic use:alcohol / prescription medications / over-the-counter preparationsDetermine client's usual 24 hour sedative-hypnotic dose.Acute WithdrawalSTAT Phenobarbital 60mg for Pulse >90 or diastolic BP >90Repeat dose every 2 hours until Pulse <90 & diastolic BP <90Calculate Phenobarbital 30mg based on the 24-hour Phenobarbital total.Complete sedative-hypnotic Symptom Assessment flow sheet with each dose.Give Phenobarbital in divided doses every hours.Hold Phenobarbital for slurred speech, ataxia, or lethargy.Note: Phenobarbital 30mg equals 1 oz. alcohol = 2oz liquor = 8oz fortified wine = 24oz beer
42 Withdrawal Management Sedative-Hypnotic “Uncovering” Uncovering: the re-appearance of withdrawal symptoms after initial stabilization, necessitating re-titration of the dose.
43 Withdrawal Management Completion of Substitution Phase Substitution is complete when the patient feels “normal,” and craving goes away.Persistence of insomnia, anxiety, pain, or depression indicate need for separate treatment of these symptoms (dual diagnosis).The patient is now ready for taper or for maintenance.
46 Effects of Increasing Dosage in the Non-tolerant User Gamma-Hydroxy-Butyrate: GHBEffects of Increasing Dosage in the Non-tolerant UserComaLoss ofConsciousnessEuphoriaSomnolenceVertigoAmnesiaSedationDose (mg/kg)
50 Nicotine Effects Withdrawal Symptoms Receptor Activation Increase arousalHeighten attentionInfluence stages of sleepProduce states of pleasureDecrease fatigueDecrease anxietyReduce painImprove cognitive functionWithdrawal SymptomsMentally sluggishInattentiveInsomniaBoredom and dysphoriaFatigueAnxietyIncrease pain sensitivityWorsen cognitive function
51 REFERENCES--- Responsibility and choice in addiction. Psychiatric Services. 53(6): (2002).Bechara A. Decision making, impulse control and loss of willpower to resit drugs: a neurocognitive perspective. Nature Neuroscience. 8: (2005)Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nature Neuroscience. 8(11): (2005).Nestler EJ, Malenka RC. The addicted brain. Scientific American.com February 9, 2004.Stalcup SA, Christian D, Stalcup JA, Brown M Galloway GP. A treatment model for craving identification and management. Journal of Psychoactive Drugs. 38:235-44, 2006Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. The Journal of Clinical Investigation. 111(10: (2003).Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. National Campaign to Prevent Teen Pregnancy. June 2005.
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