Presentation on theme: "Ted Parran, M.D. FACP Isabel and Carter Wang Chair and Professor"— Presentation transcript:
1The Opiate Epidemic Across the Life Span: Prevention and Treatment Implications Ted Parran, M.D. FACPIsabel and Carter Wang Chair and Professorin Medical EducationCWRU School of Medicine
2Opiate Misuse Use other than directed Pretty common For other indications than originally prescribedShared with others – but typically for a medical reasonFor performance enhancementFor “chemical coping”Pretty common
3Opiate Abuse or At Risk Use Planned use for intoxication/euphoriaRare adverse consequencesUse remains within peer group norms“Willful misconduct”
4Chemical Dependence – opiate as drug of choice The intermittent inconsistent repetitive loss of control over use of euphoria producing drug (EPD), causing repetitive adverse consequencesEPD’s:OpioidsStimulantsSedative-hypnoticsCannabinoidsOther
7The Pleasure Centers Affected by Opiates Opioids act not only on the central structures of the reward circuit (the ventral tegmental area and the nucleus accumbens), but also on other structures that are naturally modulated by endorphins. These structures include the amygdala, the locus coeruleus, the arcuate nucleus, and the periaqueductal grey matter, which also influence dopamine levels, though indirectly. Opiates also affect the thalamus, which would explain their analgesic effect.
8Opiate Use Related Terms ToleranceThe development of a need to take increasing doses of a medication to obtain the same effect; tachyphylaxis is the term used when this process happens quicklyDependenceThe development of substance specific symptoms of withdrawal after the abrupt stopping of a medication; these symptoms can be physiological only (ie, absence of psychological or behavioral maladaptive patterns)
9TermsAddictionThe development of a maladaptive pattern of medication use that leads to clinically significant impairment or distress in personal or occupational roles. This syndrome also includes a great deal of time used to obtain the medication, use the medication, or recover from its effects; loss of control over medication use; continuation of medication use after medical or psychological adverse effects have occurred.
10Substance Abuse v. Chemical Dependence US Adult PopulationUseAbst.SUSACDConsequences
11Substance Abuse vs Chemical Dependence Women > 70 yrs oldUseSAAbstinentSUCDConsequences
12Substance Abuse vs Chemical Dependence 18–25 yr oldsUseCDAbstinentSUSAConsequences
13Adolescents v. Older Persons: Using Alcohol and Drugs Together
14Adol Non-medical use of RX opioids: most got from a Friend or Relative
17The Prevention – Treatment Spectrum (not either / or) Primary Prevention – decrease the risk for the whole populationSecondary Prevention – target high risk groupsTertiary Prevention – treat the disease (hint…this IS Treatment)
18Morbidity and Mortality from Adol Substance Abuse 90% of date rapes annually> 70% of unanticipated teen / young adult pregnancies> 80% of interpersonal violence on college campuses> 85% of destruction of property on school campuses>> 50% of adolescent / young adult drowning incidentsTop 3 leading cause of death for year olds (OD’s etc)??% of sexually transmitted disease??% of shame and humiliation incidentsSO WE NEED PREVENTION!!!
19IS IT Cool To Be High? Adolescent Substance Misuse and Abuse Prevention
20The “MYTH” of experimentation “Experimentation” is no big deal!“Ever tried smoking” = 35% current smokers“Ever tried drinking” = 56% current, 35% bingers“Ever tried MJ” = 55% current users“Never tried drinking” = 2% smokers, 1% MJ use
21Early Drinking Initiation Related to Ever Using Illicit Drugs
23MYTH: the average age of experimentation is late adolescence Ever use in 7th / 8th and / 9th gradeTobacco = 23% / +12% / +13%Alcohol = 30% / +19% / +22%MJ = 6% / +8% / +21%After 9th grade experimentation rates increase by only 2-8% per year
24Substance abuse prevention: Risks and Resiliency's PREVETION PRINCIPLE #1There are well established risk factors and protective (resiliency) factors for substance abuse.The job of the family and community is to build protective factors and limit risk factors.Applications to RX Opiates
25Substance abuse prevention: environmental factors PREVENTION PRINCIPLE #2Environmental factors such as ease of access, price, advertising, societal norms and values play an extremely important role in encouraging or discouraging substance abuse.Limit access - minor sales / vending mach. / homeMarkedly raise taxes (price)Eliminate / alter advertisingProvide consistent messagesApplications to RX Opiates
26Substance abuse prevention: multiple levels of interventions PREVENTION PRINCIPLE #3Prevention messages must be consistentThey must be given over time (longitudinal)They must be multiple, and involve several different venues:family / school / religious institutions / sports teams and coaches / clubs / hobbies / environment / media
27Substance abuse prevention: delay use, eliminate bingeing PREVENTION PRINCIPLE #4Age of onset of experimentation is heavily associated with escalations and high risk use…SO DELAY EXPERIMENTATIONBinge use is devastating for adolescents and young adults, because judgement is exquisitely soluble in mood altering drugs…SO ZERO TOLERANCE FOR BINGEING
28A public health perspective on the disease of opiate addiction
29Chemical Dependence: a chronic disease!! High prevalenceIdentified risk factorsHints about etiologyPredictable natural historyMorbidity and mortalityGood treatment efficacyPotential for prevention
30Chemical Dependence- Treatment data Natural history studies>50% who survive ultimately get soberBrief interventionsdecrease in morbidity and mortality after BI’sSkid row detox’s - >10% one year sobrietyRecovering professionals80-85% three year sobriety ratesFor Opiates-Pharmacotherapy improves outcomes
31Opiate Dependence Treatment Options Medical Withdrawal – detox80% have physical dependence and need detoxPharmacotherapyAgonist / Partial Agonist / AntagonistCounselingSelf HelpSocial - environmental
32Treating Addictions as chronic illnesses- the challenge Study the natural historyImplement screening strategies (CAGE)Practice presenting the diagnosis (SOAPE)Assess patient’s readiness for changeNegotiate treatment plansDevelop comfort with pharmacotherapyStrategies for long-term monitoring
33HX of Pharmacotherapy of Addiction History of Pharmacotherapy:Secobarbital then Librium (valium … ativan … xanax … klonapin … son of klonapin …)AntabuseRisks: Addiction / OD / unsafe / distraction from TXNo wonder the recovering community is concerned about pharmacotherapy.Those who fail to learn from history - repeat it.
34The Pharmacotherapy of Addiction “To Prescribe or Not to Prescribe My Dear Watson … That is the Question!”Two Models:THE “HARM REDUCTION” MODELTHE “TREATMENT IMPROVEMENT” or “ADJUNT TO TREATMENT” MODEL
35“To Prescribe or Not to Prescribe” : The Harm Reduction Approach Pharmacotherapy first – Addiction TX secondCriteria the must be met:If there is an increase in morbidity in the population without the pharmacotherapy than there is with the pharmacotherapy …then provide the pharmacotherapy!(and gradually introduce additional suggested adjuncts to the pharmacotherapy that might further decrease the morbidity).
36“To Prescribe or Not to Prescribe” : Adjunct to Treatment Approach Addiction TX first – Pharma secondCriteria that MUST be met:SAFESOBRIETY / PHYSICALLYEFFICACIOUSWELL TOLERATEDINTEGRATED INTO TX PROGRAM?? NON-EUPHORIA PRODUCING
37RX for Addiction: Duration of RX Methadone maintenance data:In patient doing wellDuration of two years or longerProduced improvements in morbidityAA data:Lead in Home Group after one yearSponsor others after two years
38Longitudinal Monitoring Strategies Re-assess patient readiness for change q3m (pre-cont. and contemplative stage patients)Periodic liver function and toxicology testsAssess adherence with Tx. Prog. (release)Obtain patient and collateral report of use and Tx. Plan adherence.Monitor pharmacotherapy-get indicated labsDocument, document, document
39Opioid Antagonist therapy – transition from detox to rehab Naloxone (Narcan) available since 1970’s.Competitive antagonist at the mu receptor.Short half life, no P.O. bio-availability.Naltrexone (ReVia, Trexan) available 1985.Competitive antagonist at the mu receptor, long half life, good P.O. bio-availability.25-50mg P.O. qd for six to twelve months as adjunct to comprehensive counseling.
40Opioid antagonist therapy Blocks the feeling of a slipSlip to Relapse is interruptedTurns relapse into a planned eventMarkedly improves IOP retentionSo ….. It can really help if patients take it and stay on it!!!
41OMT – “the highest risk prescribing that is still legal” (hint – OMT = Opioid Maintenance Therapy)
42Opioid Agonist Maintenance Therapy: Methadone and Suboxone Intoxication with opioids does not produce significant judgment impairment.Like nicotineUnlike alcohol, cocaine / amphetaminesPotential for replacement therapy -nicotine replacement therapyopioid maintenance therapy
43Opioid maintenance data: Outcome OMT, on balance results in improvement in every domain of life function -familyhealthlegalemploymentfinancial
44Opioid maintenance data: Duration Duration of therapy -When should people get off?Longer = better.> 1.5 years better than < 1.5 years.Need for comprehensive longitudinal gradual approach.Need ultimate goal of abstinence.
45Summary – OB-OMT (cont) Robust monitoring program necessaryOptimize adherenceIncrease patient sobriety and quality of lifeMinimize diversionSuboxone diversion:“therapeutic diversion” per investigators“substantial financial cost” to insurersMost is excess medicine due to too high a dose
46A.A. and Abstinence Based Treatment: Medications in the Self-Help setting? A.A. Pamphlet entitled “A Letter from Bill W to the Medical Profession”A.A. pamphlet entitled “For AA Members Who are on Medication”
47Opioid Dependence: Summary Use, Abuse, Dependence, or Addiction?Maintenance v. Detox?Non-urgent, Urgent, or Emergency?Inpatient, Residential, or Outpatient?Which W/D strategy is best / avail?Post-detox pharmacotherapy!!!Transition to recovery program!!!!!
48Treating Addictions as chronic illnesses- the challenge Study the natural historyImplement screening strategies (CAGE)Practice presenting the diagnosis (SOAPE)Assess patient’s readiness for changeNegotiate treatment plans (BI – MI)Develop comfort with pharmacotherapyStrategies for long-term monitoring
49Changing the Natural History of Opiate Addiction – PREVENTION AND TREATMENT