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The Science of Recovery: Applying Neuroscience to CLINICAL Practice STIMULANT & OPIOID ADDICTION Cardwell C. Nuckols MA, PhD (407)

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Presentation on theme: "The Science of Recovery: Applying Neuroscience to CLINICAL Practice STIMULANT & OPIOID ADDICTION Cardwell C. Nuckols MA, PhD (407)"— Presentation transcript:

1 The Science of Recovery: Applying Neuroscience to CLINICAL Practice STIMULANT & OPIOID ADDICTION Cardwell C. Nuckols MA, PhD (407)

2 SUGAR OR COCAINE RATS CHOOSE HIGHLY SWEETENED SUGAR WATER OVER IV COCAINE RATS WHO WERE ALREADY COCAINE USERS (I.E. SELF-ADMINISTERED) STILL CHOOSE VERY SWEET WATER RATS ON HIGH SUGAR DIET EXHIBIT AAS WHEN WITHDRAWN Scientific American Mind Apr/May 2008, pg. 16

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4 Overview Dopamine and the Seeking System Recovery Tools – Wellness – Education Craving and Craving Mnageent Stimulants Opioids

5 SEEKING SYSTEM IN 1954 JAMES OLDS AND PETER MILNER OF MCGILL UNIVERSITY DISCOVERED WHAT THEY REFERRED TO AS THE REWARD, PLEASURE OR REINFORCEMENT SYSTEM IN 1954 JAMES OLDS AND PETER MILNER OF MCGILL UNIVERSITY DISCOVERED WHAT THEY REFERRED TO AS THE REWARD, PLEASURE OR REINFORCEMENT SYSTEM WHAT THEY ACTUALLY DISCOVERED WAS A SYSTEM THAT IS INTEGRATED THROUGHOUT THE BRAIN AND MIGHT BE BEST DESCRIBED AS THE SEEKING SYSTEM WHAT THEY ACTUALLY DISCOVERED WAS A SYSTEM THAT IS INTEGRATED THROUGHOUT THE BRAIN AND MIGHT BE BEST DESCRIBED AS THE SEEKING SYSTEM

6 SEEKING SYSTEM “THESE CIRCUITS APPEAR TO BE MAJOR CONTRIBUTORS TO OUR FEELINGS OF ENGAGEMENT AND EXCITEMENT AS WE SEEK THE MATERIAL RESOURCES NEEDED FOR BODILY SURVIVAL, AND ALSO WHEN WE PURSUE THE COGNITIVE INTERESTS THAT BRING POSITIVE EXISTENTIAL MEANING INTO OUR LIVES.”

7 SEEKING SYSTEM “HIGHER AREAS OF THE MOTOR CORTEX ARE ALSO ENERGIZED INTO ACTION BY THE PRESENCE OF DA. WITHOUT THE SYNAPTIC ‘ENERGY’ OF DA, THESE POTENTIALS REMAIN DORMANT AND STILL. WITHOUT DA, HUMAN ASPIRATIONS REMAIN FROZEN, AS IT WERE, IN AN ENDLESS WINTER OF DISCONTENT.” PANKSEEP, J. AFFECTIVE NEUROSCIENCE. OXFORD UNIVERSITY PRESS. NEW YORK, 1998, PG 144.

8 SEEKING SYSTEM WITHOUT DA ONLY THE STRONGEST EMOTIONAL MESSAGES INSTIGATE BEHAVIOR WITHOUT DA ONLY THE STRONGEST EMOTIONAL MESSAGES INSTIGATE BEHAVIOR WHEN DA SYNAPSES ARE ACTIVE IN ABUNDANCE PERSON FEELS LIKE THEY CAN DO ANYTHING WHEN DA SYNAPSES ARE ACTIVE IN ABUNDANCE PERSON FEELS LIKE THEY CAN DO ANYTHING IT IS NO MYSTERY WHY COCAINE, METHAMPHETAMINE AND OTHER DRUGS ARE SO REINFORCEING IT IS NO MYSTERY WHY COCAINE, METHAMPHETAMINE AND OTHER DRUGS ARE SO REINFORCEING

9 SEEKING SYSTEM DA EXCESS DA EXCESS – MAY SEEK SPIRITUAL HEIGHTS – APPEAR MANIC ( IN EARLIER TIMES MAY BE REPRESENTED BY SEERERS, SOOTHSAYERS, SHAMAN) – OUR IMAGINATION OUTSTRIPS THE CONSTRAINTS OF REALITY – BEGIN TO SEE CAUSALITY WHERE THERE IS ONLY CORRELATION

10 SEEKING SYSTEM DA EXCESS (CONTINUED) DA EXCESS (CONTINUED) – HIGH ANTICIPATION, INTENSE INTEREST AND INSATIABLE CURIOUSITY – MOST ARRESTING PART IS THE HUNT, NOT THE CAPTURE – DA IS RELEASED FROM THE VENTRAL STRIATUM (NUCLEUS ACCUMBENS) OF RATS QUITE VIGOROUSLY DURING THE ANTICIPATION PHASE BUT NOT DURING THE CONSUMATORY PHASE

11 SEEKING SYSTEM CRITICAL CIRCUITS CRITICAL CIRCUITS – MEDIAL FOREBRAIN BUNDLE OF THE LATERAL HYPOTHALAMUS (LH) – EXTENDED LATERAL HYPOTHALAMIC CORRIDOR (LH) RESPONDS TO HOMEOSTATIC IMBALANCES (BODY NEED STATES) RESPONDS TO HOMEOSTATIC IMBALANCES (BODY NEED STATES) ENVIRONMENTAL INCENTIVES ENVIRONMENTAL INCENTIVES – LH CONTINUUM RUNNING FROM VTA TO NAc WHEN EVOKED GET STRONGEST AND MOST ENERGIZED EXPLORATION AND SEARCH BEHAVIORS WHEN EVOKED GET STRONGEST AND MOST ENERGIZED EXPLORATION AND SEARCH BEHAVIORS

12 SEEKING SYSTEM CRITICAL CIRCUITS (CONTINUED) CRITICAL CIRCUITS (CONTINUED) – BASIC IMPULSE TO SEARCH, INVESTIGATE AND MAKE SENSE OF ENVIRONMENT EMERGES FROM THE CIRCUITS THAT COURSE THRU THE LH – NEUROEMOTIONAL SYSTEM THAT DRIVES AND ENERGIZES MANY MENTAL COMPLEXITIES THAT HUMANS EXPERIENCE SUCH AS PERSISTENT FEELINGS OF INTEREST, CURIOUSITY, SENSATION SEEKING AND IN THE PRESENCE OF A SUFFICIENTLY COMPLEX CORTEX-THE SEARCH FOR HIGHER MEANING

13 SEEKING SYSTEM SENSITIZED BY SENSITIZED BY – EXTERNAL STIMULI THAT CAN HAVE EITHER STRONG OR WEAK INTERACTIONS WITH THIS EMOTIONAL SYSTEM – HELPS MEDIATE APPETITIVE LEARNING SO THAT ANIMALS WILL BECOME EAGER AND EXHIBIT EXPECTANCIES IN RESPONSE TO PREVIOUSLY AROUSING CUES (REINFORCEMENT)

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15 Dopamine D2 Receptors Association between DA D2 receptor numbers and drug self-administration – Increased D2 receptors reduced alcohol consumption – Decreased D2 receptors higher risk DA D2 receptor levels influenced by stress and social hierarchy DA D2 receptor levels influenced by stress and social hierarchy Helps explain influence of environment and genes

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17 Environment And Social Status Subordinate animals more likely to self-administer cocaine Dominant animals no more likely to self-administer cocaine than placebo Social interventions can change neurobiology Social interventions can change neurobiology – Increased DA D2 receptors – Reduced self-administration Behavioral interventions could counteract the aversive effects of drug abuse and reinforce the power of group approaches Behavioral interventions could counteract the aversive effects of drug abuse and reinforce the power of group approaches

18 Group Behavioral Interventions Group Therapy – Active participation – Successful completion of assignments Milieu – Leadership – Modeling Self help – Coffee and chairs – “Telling story”

19 Recovery & Epigenesis Facilitated by: – NOVELTY – ENVIRONMENTAL ENRICHMENT – PHYSICAL EXERCISE – NUTRITION – PLAY BDNF BDNF

20 Novelty-Examples Group Therapy Group Therapy Individual Counseling Individual Counseling Sober Living Sober Living Higher Power Higher Power Assessment Assessment – Alcohol/Drug – Psychosocial

21 Environmental Enrichment- Examples Recovery housing Recovery housing Healthy milieu Healthy milieu Self help meetings Self help meetings Church Church From isolation to living “one day at a time” in the presence of others striving for a more fulfilling life From isolation to living “one day at a time” in the presence of others striving for a more fulfilling life

22 Physical Exercise Stimulates production of brain-derived neurotrophic factor (BDNF) Stimulates production of brain-derived neurotrophic factor (BDNF) – Neurotrophin that governs maturation and development of neural systems Enhances executive functioning Enhances executive functioning – Obey social rules – Adapt to changing & unpredictable environment – Short term working memory – Multi-tasking – Self-directedness

23 Physical Exercise Self-directedness Self-directedness – Responsible – Purposeful – Resourceful Increases neurotransmitters Increases neurotransmitters Monoamines Monoamines – Serotonin – Dopamine – Norepinephrine

24 Education Why give an alcoholic or addict a 60 minute didactic or video? Why give an alcoholic or addict a 60 minute didactic or video? A new format – minute simple didactic How to participate in treatment – 10 minute questionnaire – 30 minute discussion group

25 10 Minute Questionnaire I THINK……….. I FEEL………….. I LEARNED…… MY FUTURE BEHAVIOR WILL CHANGE…

26 CRAVING  CLASSIFIACTION OF CRAVING  Situational triggers  Environment (People, Places And Things)  Emotional triggers  Internal (Hungry, Angry, Lonely, Tired, Reward and Bored)  Acute Abstinence Syndrome  Stress

27 CRAVING: MOST COMMON CRAVING TRIGGERS  In presence of:  Alcohol and drugs  Alcohol and drug users  Places where used to use or purchase  Negative feeling states particularly anger but also:  Boredom  Loneliness  Fear  Anxiety

28 MOST COMMON CRAVING TRIGGERS Positive feeling states Physical pain Use of mood-altering prescription drugs Suddenly having a lot of cash Complacency Insomnia Sexual functioning

29 STIMULANT ADDICTION: Childhood Trauma History and Methamphetamine Addiction 44% of women and 24% of men entering treatment for methamphetamine addiction report childhood sexual abuse 32% of women and 34% of men report childhood physical abuse 56% reported parental alcohol and/or drug problems Multigenerational Brown University Digest of Addiction Theory and Application. May 2004

30 STIMULANT ADDICTION: Meth's Long Lasting Effects STIMULANT ADDICTION: Meth's Long Lasting Effects Neuron (April 10, 2008) Bamford, Nigel Novelty causes increased DA Increased DA causes reduced Glutamate – Causes filtering of irrelevant information and strong focus on a single object or event – After novelty disappears DA is reduced and Glutamate returns to normal

31 STIMULANT ADDICTION: Meth's Long Lasting Effects STIMULANT ADDICTION: Meth's Long Lasting Effects Neuron (April 10, 2008) Bamford, Nigel In chronic meth use… – Meth causes increased DA and reduced Glutamate – After drug is gone glutamate stays low in spite of reduced DA – Source of continuing low Glutamate is Acetylcholine – After prolonged meth use Acetylcholine stays low effectively blocking Glutamate release.

32 STIMULANT ADDICTION: Meth's Long Lasting Effects Paranoid psychosis – Homicidal and suicidal thought, rage, violence and hallucinations Generally angry toward people they know and paranoid toward strangers or strange situations Damage to dopamine-producing neurons Damage to dopamine-producing neurons Damage to serotonin-producing neurons Damage to serotonin-producing neurons Effects on cognition and affect (depression) Damage to heart and blood vessels Skin abscesses and skin infections Increased risk of Hepatitis B and C, HIV

33 CRAVING MANAGEMENT  Psychotherapy  Group Approaches  Behavior Therapy  Structure  Recovery Foundation Program  Changing patterns  Safety Plan  Pharmacotherapy

34 Stimulant Treatment Cognitive-Behavioral strategies to promote abstinence and prevent relapse – Avoidance of “high risk” situations – Educating about “triggers” and “craving” – Training in “thought stopping” – Reinforcing principles of verbal praise by therapist and peers

35 Stimulant Treatment Relapse – Reframe event, not a failure – May need to go back to Early Recovery Sessions – Repeated as indicator of need for more restrictive level of care Urinalysis – Reevaluate the period surrounding the test – Give patient opportunity to explain – Don’t get into validity of test argument – May need to increase number of tests – Consider LOC

36 STAGES OF RECOVERY BEGINNING (1-6 Weeks ) Withdrawal Honeymoon MIDDLE (6-20 Weeks ) Wall ADVANCED (20+ Weeks ) Adjustment PAW

37 Roadmap for Recovery Early Abstinence Features (Honeymoon) Overconfidence Difficulty Concentrating Continued Memory Problems Intense Feelings Mood Swings Other Substance Abuse Inability to Prioritiz e

38 Roadmap for Recovery Techniques for Thought Stopping Learn to recognize “using thoughts” Use visual imagery Relaxation Prayer Call someone

39 Thought Stopping First one must become aware of their automatic thoughts-need some form of self- monitoring Second one must have an alternative positive thought or behavior to put in its place Some people get “rebound effect”

40 Thought Stopping Thought Replacement Thought Replacement Yelling “stop” Yelling “stop” Replacement visual image Replacement visual image Aversive replacements Aversive replacements Using rubber bands Using rubber bands

41 Roadmap for Recovery Return to Old Behaviors Anhedonia Anger Depression Emotional Swings Unclear Thinking Isolation Family Problems Cravings Return Irritability Abstinence Violation

42 What Is Protracted Abstinence Syndrome (PAW) STRESS SENSITIVE STRESS SENSITIVE NEUROLOGICAL SYNDROME NEUROLOGICAL SYNDROME STARTS AFTER THE ACUTE ABSTINENCE SYNDROME STARTS AFTER THE ACUTE ABSTINENCE SYNDROME LASTS FOR MONTHS (SOMETIMES MORE) INTO RECOVERY LASTS FOR MONTHS (SOMETIMES MORE) INTO RECOVERY FOR METH 6-20 WEEKS FOR METH 6-20 WEEKS

43 CORE SYMPTOMS SYMPTOM SEVERITY BASED ON LEVEL OF NEUROLOGICAL DYSFUNCTION AND DEGREE OF PSYCHOSOCIAL STRESS – Restlessness and Irritability – Euphoric Content Dreams – Anxiety – Distractibility – Intense Craving – Executive Functioning – Visual-spatial

44 MANAGEMENT OF PAW (NEUROPSYCHOLOGICAL REHABILITATION) RELATIONAL AND SPIRITUAL EDUCATION – MANAGEMENT OF CRAVING AND PAW LIFESTYLE ASSESSMENT – NUTRITIONAL – SLEEP/WAKE BEHAVIORAL MANAGEMENT – FOUNDATION PROGRAM – SAFETY PLAN PHARMACOLOGICAL

45 Pharmacological Management-Reducing Relapse Stimulant drugs-Cocaine and Methamphetamine – Gamma-vinyl GABA (Vigabatrin) Attenuates or blocks reward seeking behaviors – Modafinil (Provigil) Treatment for Narcolepsy Increases mood, energy, and sense of well-being Reduces daytime sleepiness – Selegiline (Carbex, Atapryl) MAOI Believed to restore depleted dopamine

46 Changing Patterns 31 yo Nicki-a recovering methamphetamine addict- just got her first paycheck. She cashed her check and cruised thru the neighborhood where she used to score dope. Rock music blared from her speakers. Soon she was thinking, "I worked hard all week. I deserve a little fun.”

47 Behavioral Foundation Program In an inpatient setting the patient schedule serves this purpose On an outpatient basis or upon discharge from inpatient a recovery plan or contract is appropriate Remember that most addicts have little or no recent experience living a drug free lifestyle

48 Behavioral Foundation Program TASKMONTUWEDTHUFRISATSUN SH TX FUN NUT PEX

49 Behavioral Foundation Program Carter is 24 yo and just getting out of treatment for alcohol and drug addiction His early A/D history included…. – Started drinking on Friday nights with friends in high school – Turned-on to methamphetamine and marijuana by friends on weekends – Started to buy drugs to sell from a distributor on Wed nights

50 Using Early Drug History TASKMONTUWEDTHUFRISATSUN SH X X TX X FUN X NUT PEX

51 Behavioral Safety Plan CT: “Last night I had a dream that I was getting ready to shoot dope-it was all on the table in front of me. It was like five minutes before I knew it was a dream.” TH: “Congratulations on not using, tell the group what you did to deal with the craving.” CT: “ I went into the kitchen and wrote in my journal everything that happened. Then I said a prayer.”

52 Behavioral Safety Plan TH: What else could you have done? CT: “I know that I can always call my sponsor or my lover. I can also read from a book that I have on recovery or a book of affirmations that I like.” TH: “That’s great. Now let’s make a safety plan from what you have discovered.”

53 Behavioral Safety Plan On 3x5 Index Card MY PERSONAL SAFETY PLAN Remember that craving go away I can write in my journal I can call my sponsor ( ) I can call my lover ( ) I can read from my favorite recovery book I can read affirmations

54 Behavioral Safety Plan On 3x5 Index Card  TH: “On the back of the index card, come up with a saying or a prayer that gives you comfort and strength.” ‘Lord help me to be the best possible person I can be today’.”  CT: “ I have always liked ‘Lord help me to be the best possible person I can be today’.”

55 Stimulant Addiction: Medical Management Modafinil Agents that increase GABA – Topiramate – Vigabatrin (gamma-vinyl-GABA)

56 OPIOIDS Natural – Morphine – Codeine Semi-synthetic – Heroin – Oxycodone Tylox Percodan OxyContin

57 OPIOIDS Semi-synthetic – Oxymorphone Dilaudid Numorphan – Hydrocodone Lortab Vicodin Synthetics – Methadone – Propoxyphene – Lomotil

58 Heroin Abstinence Syndrome Increased Noradrenergic activity Begins hours after last dose Peaks at 2-3 days Lasts 7-10 days

59 Symptoms of the Abstinence Syndrome Addicts Experience – A hyper-aroused state(“fight or flight”) Increased : – Heart rate – Blood pressure – Restlessness – Tremors – Hypervigilence – Dilated pupils

60 Symptoms of the Abstinence Syndrome Addicts experience – Worst case of flu imaginable Nausea and vomiting Runny nose Cold, shivering Cramping Tearing Diarrhea

61 Subjective Experience 4 levels of experience – High – Abnormally normal – Subjective withdrawal – Physical withdrawal Routes of administration – IV – Oral – Pulmonary

62 Pharmacological Treatment Acute Methadone. – Inpatient. 40 mg. In 4x10mg doses. Observe every 2 hours. If sleepy reduce next dose by 5mg. In withdrawal add 5mg. After 24 hours withdraw at a 5mg. per day rate.

63 Pharmacological Treatment Acute Methadone – Outpatient mg. Divided into 2 doses After 2 nd day withdraw at 2.5mg. per day Clonidine(Catapress TTS) – 1.2mg. Per day in 3 divided doses – 2 or 3 #2 patches – May mask sedative/hypnotic withdrawal – Can combine with Phenobarbital Lofexidine

64 Rapid Detoxification Procedure administered in ICU Use of anesthesia Opiate receptor blocker(Naltrexone) Physical reaction closely monitored Process complete in 4-6 hours

65 Symptomatic Treatment PRN meds for the first days. – Bentyl 10mgs. for abdominal cramps. 30mgs. po q 4-6hours. – Imodium 2mgs. for diarrhea. 1-2 caps after 1 st observed stool. Not to exceed 60 mgs. Per day. – Robaxin 750mgs. for muscle spasm or pain. 1-2 q 6-8 hours.

66 Pharmacological Maintenance Opioid Maintenance Medications Opioid Maintenance Medications – Methadone – LAAM – Buprenorphine – Naltrexone

67 Pharmacological Naltrexone (Revia, Vivitrol) Naltrexone (Revia, Vivitrol) Pure antagonist Pure antagonist Poor compliance Poor compliance – Less than 10% for street addicts Better compliance Better compliance – Healthcare professionals – Parole/Probation New suspension with q30d administration should dramatically increase compliance and reliability of drug New suspension with q30d administration should dramatically increase compliance and reliability of drug

68 Approved Buprenorphine Products Subutex-Buprenorphine. sublingual (SL) Subutex-Buprenorphine. sublingual (SL) – 2mg and 8mg tablets Suboxone-Buprenorphine/Naloxone SL tablets Suboxone-Buprenorphine/Naloxone SL tablets Buprenorphine x’s more potent than morphine Buprenorphine x’s more potent than morphine Partial agonist Partial agonist – Increasing dose does not increase effect like a full agonist

69 Buprenorphine-Affinity and Dissociation Very high affinity for mu opioid receptor Very high affinity for mu opioid receptor Mu receptor will choose buprenorphine over other opioids Mu receptor will choose buprenorphine over other opioids Buprenorphine will displace other opioids Buprenorphine will displace other opioids Slow dissolution from mu receptor Slow dissolution from mu receptor – Half-life on receptor is hrs – Heroin on and off receptor in millisecond – At Buprenorphine dose of 16mg almost no binding to other opioids

70 Combination of Buprenorphine and Naloxone  If taken under the tongue you get predominant buprenorphine effect  If dissolved and injected get predominant naloxone effect (precipitates withdrawal)

71 Buprenorphine Induction Buprenorphine equally effective as 60 mg of Methadone per day Buprenorphine equally effective as 60 mg of Methadone per day If patient needs or more mgs of Methadone to be comfortable, Buprenorphine probably will not work If patient needs or more mgs of Methadone to be comfortable, Buprenorphine probably will not work With client dependent on short-acting opioids With client dependent on short-acting opioids – Instruct client to abstain for hours – Need to be in mild withdrawal before first d – Need to be in mild withdrawal before first dose

72 DOPAMINE (DA) TONE TWO TYPES OF LOW DA TONE TWO TYPES OF LOW DA TONE – DA RECEPTOR SIGNAL AT NUCLEUS ACCUMBENS (NAc) – OPIOID RECEPTOR SIGNAL AT VENTRAL TEGMENTAL AREA (VTA) CAN INVOLVE ANY PART OF MECHANISM FOR SIGNAL CONDUCTION CAN INVOLVE ANY PART OF MECHANISM FOR SIGNAL CONDUCTION TWO NEUROTRANSMITTER SYSTEMS FORM A POSITIVE FEEDBACK LOOP, EACH CAUSES AN INCREASE IN THE OTHER TWO NEUROTRANSMITTER SYSTEMS FORM A POSITIVE FEEDBACK LOOP, EACH CAUSES AN INCREASE IN THE OTHER – WHEN NOT FUNCTIONING PROPERLY GET LESS THAN NORMAL HEDONIC RESPONSE TO STIMULI

73 Nucleus Accumbens VentralTegmentalArea Dopamine Opioid Peptides Naltrexone Arcuate Nucleus Reward Pathways

74 DOPAMINE (DA) TONE TWO TYPES OF LOW DA TONE (CONTINUED) TWO TYPES OF LOW DA TONE (CONTINUED) SYMPTOMS WILL BE THOSE OF REDUCED DA TONE AT NAc REGARDLESS OF THE LOCATION OF FEEDBACK PROBLEM SYMPTOMS WILL BE THOSE OF REDUCED DA TONE AT NAc REGARDLESS OF THE LOCATION OF FEEDBACK PROBLEM FROM TREATMENT PERSPECTIVE WHAT DIFFERENTIATES WHETHER DA OR OPIOID CAUSATION OF LOW DA TONE IS…. FROM TREATMENT PERSPECTIVE WHAT DIFFERENTIATES WHETHER DA OR OPIOID CAUSATION OF LOW DA TONE IS…. – HISTORY OF DRUG USAGE AND EFFECTS THAT USER EXPERIENCES

75 DOPAMINE (DA) TONE DA RECEPTOR SIGNAL AT NAc DA RECEPTOR SIGNAL AT NAc – COULD HAVE NORMAL FUNCTIONING VTA AND NORMAL FUNCTIONING OPIOID RECEPTOR ON VTA LIKE DRUGS THAT CAUSE DIRECT INCREASE IN DA AT THE NAc OR DIRECTLY STIMULATE THE NAc LIKE DRUGS THAT CAUSE DIRECT INCREASE IN DA AT THE NAc OR DIRECTLY STIMULATE THE NAc DRUGS ACTING ON OPIOID RECEPTOR WILL NOT PROVIDE MUCH OF A REWARD BECAUSE SYSTEM IS FUNCTINING NORMALLY DRUGS ACTING ON OPIOID RECEPTOR WILL NOT PROVIDE MUCH OF A REWARD BECAUSE SYSTEM IS FUNCTINING NORMALLY MAY USE OPIOIDS BUT AT BEST WILL BE A SECOND CHOICE MAY USE OPIOIDS BUT AT BEST WILL BE A SECOND CHOICE DOC WILL BE STIMULANTS OF ALL TYPES INCLUDING NICOTINE DOC WILL BE STIMULANTS OF ALL TYPES INCLUDING NICOTINE

76 DOPAMINE (DA) TONE OPIOID RECEPTOR SIGNAL AT VTA OPIOID RECEPTOR SIGNAL AT VTA – DRUGS THAT INCREASE DA NOT AS EFFECTIVE – DOC ARE OPIOID AGONISTS – COCAINE DOESN’T WORK VERY WELL UNLESS COMBINED WITH OPIOID – METHAMPHETAMINE CAUSES ADDITIONAL RELEASE OF DA AT NAc RATHER THAN JUST REUPTAKE INHIBITION (MIMICS THE EFFECT OF OPIOID), NICOTINE STIMULATES DA RELEASE PT. MAY STATE THAT LIKES METH AND COKE DOESN’T WORK VERY WELL PT. MAY STATE THAT LIKES METH AND COKE DOESN’T WORK VERY WELL

77 DOPAMINE (DA) TONE COULD HAVE BOTH TYPES OF REDUCED DA TONE (DA AND OPIOID) COULD HAVE BOTH TYPES OF REDUCED DA TONE (DA AND OPIOID) – OCCURS IN APPROXIMATELY ONE-HALF OF OPIOID DEPENDENT PTS IF GIVE THEM BUPRENORPHINE MAY CONTINUE TO SMOKE OR SMOKE MORE IF GIVE THEM BUPRENORPHINE MAY CONTINUE TO SMOKE OR SMOKE MORE – VTA MAKES MORE DA SO SMOKING IS MORE REWARDING » EVIDENCE OF LOW DA TONE

78 DOPAMINE (DA) TONE BUPRENORPHINE BUPRENORPHINE – PARTIAL MU AGONIST – KAPPA OPIOID ANTAGONIST ANECDOTAL PERSPECTIVES BUPRENORPHINE/NALOXONE (SUBOXONE) ANECDOTAL PERSPECTIVES BUPRENORPHINE/NALOXONE (SUBOXONE) – TITRATION WORKS BEST WHEN PERFORMED QUICKLY KEEPS PTS FROM LEAVING TREATMENT DUE TO UNDER DOSING KEEPS PTS FROM LEAVING TREATMENT DUE TO UNDER DOSING USING 10 POINT SCALE (1 IS FEELING COMPLETELY OK AND 10 IS WORST I’VE FELT OFF OF OPIOIDS) USING 10 POINT SCALE (1 IS FEELING COMPLETELY OK AND 10 IS WORST I’VE FELT OFF OF OPIOIDS)

79 DOPAMINE (DA) TONE TITRATION WORKS BEST WHEN PERFORMED QUICKLY (CONTINUED) TITRATION WORKS BEST WHEN PERFORMED QUICKLY (CONTINUED) – TAKE 4 MG AND CALL IN 2 HOURS – IF NOT AT 1 TAKE 4 MG AND CALL IN 2 HOURS – CONTINUE UNTIL PT IS COMFORTABLE – MAY GET HIGHER INTIAL DOSE THIS WAY BUT CAN REDUCE AFTER 1 WEEK SWALLOWING BUPRENORPINE MAY CREATE ADVERSE SYMPTOMS OF “HEADACHE” OR “NAUSEA” SWALLOWING BUPRENORPINE MAY CREATE ADVERSE SYMPTOMS OF “HEADACHE” OR “NAUSEA” – MAY BE RELATED TO SWALLOWING THE BURPENORPINE/NALOXE/SALIVA MIXTURE – SWALLOWING MAY CAUSE INCREASE IN NALOXONE ACTIVITY

80 DOPAMINE (DA) TONE SWALLOWING BUPRENORPINE MAY CREATE ADVERSE SYMPTOMS OF “HEADACHE” OR “NAUSEA” (CONTINUED) SWALLOWING BUPRENORPINE MAY CREATE ADVERSE SYMPTOMS OF “HEADACHE” OR “NAUSEA” (CONTINUED) – HAVE PT LEAN FORWARD IN CHAIR AND READ FOR 10 MINUTES – SPIT OUT SALIVA IF PT SAYS THAT SUBOXONE MAKES THEM “NOD OUT” IF PT SAYS THAT SUBOXONE MAKES THEM “NOD OUT” – HIGHLY UNLIKELY THAT SUBOXONE WILL CAUSE THIS – CHECK TO SEE IF THEY HAVE EATEN A HEAVY MEAL PRIOR TO TAKING MED OR IF THERE IS A SLEEP PROBLEM IN ADDICTION MEDICINE THE ONLY TIME THAT SUBUTEX SHOULD BE USED IS WITH PREGNANT FEMALE IN ADDICTION MEDICINE THE ONLY TIME THAT SUBUTEX SHOULD BE USED IS WITH PREGNANT FEMALE – CONCERN AT HIGH DOSES (EXAMPLE 32 MG) MAY ABSORB ENOUGH NALOXONE TO CAUSE PROBLEMS-THIS IS EXTREMELY RARELY THE CASE

81 DOPAMINE (DA) TONE – WHEN USING SUBOXONE FOR PAIN BURENORPHINE IS A VERY POTENT PAIN RELIEVER BURENORPHINE IS A VERY POTENT PAIN RELIEVER ADDICTION STABILIZATION EFFECT IS LONG LASTING ADDICTION STABILIZATION EFFECT IS LONG LASTING HOWEVER, PAIN RELIEF EFFECT IS SHORT ACTING HOWEVER, PAIN RELIEF EFFECT IS SHORT ACTING THEREFORE DIVIDE THE DOSE INTO SMALLER PORTIONS AND GIVE MORE FREQUENTLY THEREFORE DIVIDE THE DOSE INTO SMALLER PORTIONS AND GIVE MORE FREQUENTLY – FOR EXAMPLE, IF ON 16 MG QD, GIVE 4MG QID


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