3 Objectives Definition of Addiction Diagnostic Criteria Contributing factorsNeurobiology of addiction, tolerance & withdrawal
4 Addiction – CSAM definition A primary, chronic disease characterized by impaired control over the use of a psychoactive substance or behaviour.Clinically the manifestations occur along biological, psychological, social & spiritual dimensions.Like other chronic diseases, it can be progressive, relapsing & fatal.
5 Addiction- CSAM definition 2 Common features are change in mood, relief from negative emotions, provision of pleasure,preoccupation with the use of substances or ritualistic behaviour; &continued use of substances &/or engagement in behaviour despite adverse physical, psychological &/or social consequences.
6 DSM IV substance abuseA maladaptive pattern of use leading to clinically significant distress – at least 1 criterion met within a 12 month periodRecurrent substance use resulting in a failure to fulfill major role obligations at work, school, or homeRecurrent substance use in situations in which it is physically hazardousRecurrent substance-related legal problemsContinued substance use despite having persistent or recurrent social or interpersonal problems caused by the effects of substance useDeliberate use of the substance to achieve intoxicationHas never met the criteria for Substance DependenceB.
7 Substance Dependence-DSM IV A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 or more of the following over a 12 month period:-Tolerance –diminished effect with use of the same amount, or increased amount used to achieve intoxication.-Withdrawal – characteristic withdrawal syndrome for the substance, or the same or closely related substance is taken to relieve or avoid withdrawal symptoms.Which is what we defined as addiction
8 Substance Dependence-DSM IV The substance was taken in larger amounts or for a longer period than was intendedThere is a persistent desire or unsuccessful attempts to cut downA great deal of time is spent in activities to procure the substanceImportant activities are given up or reduced because of the substanceThe substance use is continued despite knowledge of having a physical or psychological problem caused by or exacerbated by the substance use.
9 Anyone who uses a benzodiazepine or an opiate for several weeks can develop physical dependence. This is not sufficient criteria to diagnose addiction.
10 The Hallmark of Addiction The 4 ‘C’s-Loss of Control of use of the substance-Compulsive use or Craving-Continued use despite adverse Consequences
11 ‘Pseudo – addiction’This is a term which is used to describe patient behaviors which may occur when pain is undertreated. They may appear to be drug focused & drug seeking , but the behaviors resolve when pain is effectively treated.
12 Contributing Factors : Opioid Risk Tool Family Hx of Substance AbuseAlcoholIllegal DrugsRx DrugsPersonal Hx of Substance AbuseHistory of Preadolescent Sexual AbusePsychological DiseaseADHD, OCD, Bipolar, SchizophreniaDepressionWebster LR 2005
13 How do Opiates Work Pharmacology Opiate receptors in the brain: several types - mu, delta, kappa - most important in addiction is the mu receptorAnalgesia & euphoriaSide effects: respiratory depression, sedation,nausea & constipation, low BP, pupils constrictIncreased activity in the ventral tegmental area of the brain resulting in increased dopamine release in the nucleus accumbens = highly addictiveEndorphines - our natural opiates
14 Opiod agonist mediates the inhibition of release of GABA - results in disinhibition of of the dopamine neurons - Increased dopamine release at NA
15 Human Molecular Genetics 5 single nucleotide polymorphisms have been identified in the coding region of the human mu opioid gene3 of these lead to amino acid changes in the receptorSome receptor variants have been associated with increased potency of activation of the receptorSome have some association with increased vulnerability to dependenceYou are actually inheriting a pattern of responding to the drug differently from the non-addict More research needed
16 Tolerance The brain adapts to the constant presence of the opiate It takes more drug to get the euphoriaTolerance to respiratory depression doesn’t develop so quicklyTherefore there’s always risk of death from overdoseAcute morphine ingestion effect is mediated by inhibition of adenyl cyclase - inhibition of CAMP dependent cascade . Long term this is compensated for by an increase in adenyl cyclase Physiologic changes within the cell’s metabolism as the cells adapt to the constant exposure to opiates - they become less responsive to the stimulus at the receptor - so more drug is needed to get the same effect. Tolerance to different effects develops at different pace
17 WithdrawalNeurophysiological rebound in the organ systems on which opioids have their primary actionsCNS suppression --CNS over activityIncreased CNS noradrenergic hyperactivity primarily at the nucleus ceruleusLarge body of research evidence supports this. Methadone Maintenance is associated with reduced use of illicit opiates, reduced IV use , improved health, reduced crime & improved social function re work & family function
19 Withdrawal Worst at day 3-4 Longer withdrawal for methadone Improving by day 10Sweats can persist 3-4 weeksEmotional lability will persist for weeksInsomnia can last 6 months or moreAT day 10 still c/o sweats , aching , poor sleep, irritable . GI sympt have usua;;y settled.
20 Addiction Treatment Works Many medical practitioners have a negative attitude towards dealing with addictionPatients DO respond to brief interventions in the doctor’s office, to rehabilitation programs, & to methadone maintenance programsDespite the research evidence our patients still have to deal with the stigma which is attached to the diagnosis of addiction & methadone treatment. Large body of research evidence supports this. Methadone Maintenance is associated with reduced use of illicit opiates, reduced IV use , improved health, reduced crime & improved social function re work & family function Within the community at large & within the medical communityOur goal is to educate & improve the understanding of addiction & its treatment