ADDICTION in Family Practice

1. ADDICTION in Family Practice Adam Newman MD CCSAM Assistant Professor Department of Family Medicine

2. Objectives • Definition • Epidemiology • Disease model • Natural History • Treatment Case Study: Opiate Addiction & Substitution Therapy

3. 1. DEFINITION

4. DSM IV Diagnosis A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the past 12 months:

5. DSM IV diagnosis (cont’d) 1 Tolerance 2 Withdrawal 3 A great deal of time is spent obtaining, using, or recovering from the substance 4 Sacrifice of social, occupational, or recreational activities 5 The substance is taken in larger amounts or over a longer period than was intended 6 There is a persistent desire or unsuccessful attempts to cut down or control use 7 Use is continued despite negative physical or psychological effects

6. Definition of Addiction: the three C’s • Compulsive drug use/behaviour • Inability to Control use/behaviour • Continued use/behaviour despite negative Consequences

7. The three C’s: 1 Tolerance 2 Withdrawal 3 A great deal of time is spent obtaining, using, or recovering from the substance 4 Sacrifice of social, occupational, or recreational activities 5 The substance is taken in larger amounts or over a longer period than was intended 6 There is a persistent desire or unsuccessful attempts to cut down or control use 7 Use is continued despite negative physical or psychological effects

8. The three C’s: 1 Tolerance 2 Withdrawal 3 A great deal of time is spent obtaining, using, or recovering from the substance COMPULSION 4 Sacrifice of social, occupational, or recreational activities COMPULSION 5 The substance is taken in larger amounts or over a longer period than was intended 6 There is a persistent desire or unsuccessful attempts to cut down or control use 7 Use is continued despite negative physical or psychological effects

9. The three C’s: 1 Tolerance 2 Withdrawal 3 A great deal of time is spent obtaining, using, or recovering from the substance [COMPULSION] 4 Sacrifice of social, occupational, or recreational activities [COMPULSION] 5 The substance is taken in larger amounts or over a longer period than was intended CONTROL 6 There is a persistent desire CONTROL or unsuccessful attempts to cut down or control use 7 Use is continued despite negative physical or psychological effects

10. The three C’s: 1 Tolerance 2 Withdrawal 3 A great deal of time is spent obtaining, using, or recovering from the substance [COMPULSION] 4 Sacrifice of social, occupational, CONSEQUENCES or recreational activities [COMPULSION] 5 The substance is taken in larger amounts or over a longer period than was intended [CONTROL] 6 There is a persistent desire [CONTROL] or unsuccessful attempts to cut down or control use 7 Use is continued despite negative physical or psychological effects CONSEQUENCES

11. The three C’s: 1 Tolerance 2 Withdrawal 3 A great deal of time is spent obtaining, using, or recovering from the substance [COMPULSION] 4 Sacrifice of social, occupational, [CONSEQUENCES] or recreational activities [COMPULSION] 5 The substance is taken in larger amounts or over a longer period than was intended [CONTROL] 6 There is a persistent desire [CONTROL] or unsuccessful attempts to cut down or control use 7 Use is continued despite negative physical or psychological effects [CONSEQUENCES]

12. DSM IV Tolerance & Withdrawal 1) Tolerance, as defined by either of the following: i) a need for markedly increased amounts of the substance to achieve intoxication or desired effect ii) markedly diminished effect with continued use of the same amount of the substance 2) Withdrawal, as manifested by either of the following: i) the characteristic withdrawal syndrome (refer to Criteria A and B for specific substance) ii) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

13. Pseudoaddiction: • Both Tolerance and Withdrawal will occur in any patient treated with long-term opiate therapy for whatever reason • Tolerance and Withdrawal are neither necessary or sufficient to diagnose addiction.

14. Who Is An Addict? “Our whole life and thinking was centered in drugs in one form or another—the getting and using and finding ways and means to get more. We lived to use and used to live. Very simply, an addict is a man or woman whose life is controlled by drugs. We are people in the grip of a continuing and progressive illness whose ends are always the same: jails, institutions, and death” the Little White Booklet, Narcotics Anonymous 1986

15. 2. EPIDEMIOLOGY

16. Epidemiology of Addiction • 1 in 5 Canadians experience mental illness in their lifetime; of these, 20% have a co-occurring substance use problem • 1 in 10 Canadians report symptoms consistent with illicit drug dependence Canadian Alcohol and Drug Use Monitoring Survey 2009

17. Epidemiology • An estimated 25% of male drinkers and 9% of female drinkers meet criteria for high-risk drinking • 200,000 Canadians are currently addicted to painkillers • $40 Billion are spent on addiction-related injuries and treatment a year in Canada www.camh.ca

18. Epidemiology • “As few as 1 in 20 substance abusing patients coming for medical attention has his substance abuse problem recognized” • Gorroll, May, Mulley pg 1078

19. Epidemiology • Physician advice reduces alcohol consumption among problem drinkers and alcohol-dependent patients • Patients showed decreases in hospitalizations, ER visits, health care costs and mortality if their primary practitioner had addiction medicine training • Kahan M, Wilson L, Midmer D, Ordean A, Lim HY Short-term outcomes in patients attending a primary care-based addiction shared care program Can Fam Physician 2009; 55:1108-9

20. 3. DISEASE MODEL

21. Disease Model: evidence 1. Consistent Medical History, Signs and Symptoms (across ethnic, cultural and socioeconomic boundaries) 2. Strong Tendency to Relapse (despite long periods of abstinence) 3. Cravings (induces use despite powerful social sanctions & effects contrary to patient’s own interests) 4. Pathophysiologic Changes in the Brain following continuous exposure (D2 receptors, glucose metabolism, twin studies, PET scan studies)

22. Disease Model • “It is estimated that 40 – 60% of the vulnerability to addiction is attributable to genetic factors” • Volkow ND, Li TK, Drug Addiction: the Neurobiology of Behavior gone Awry • In: Principles of Addiction Medicine 2010

23. Disease Model

26. Why Can’t Addicts Just Quit? Non-Addicted Brain Addicted Brain Control Control Saliency Drive NO GO GO Drive Saliency Memory Memory Because Addiction Changes Brain Circuits Adapted from Volkow et al., Neuropharmacology, 2004

27. Disease Model?! • “In our detailed study of over 17,000 middle-class American adults of diverse ethnicity, we found that the compulsive use of nicotine, alcohol, and injected street drugs increases proportionally in a strong, graded, dose-response manner that closely parallels the intensity of adverse life experiences during childhood… Our findings are disturbing to some because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers or dangerous chemicals”. • Felitti,VJ. The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study. 2004

28. Biopsychosocial Model

29. Why Become Addicted? • Cost-benefit: the more deprived the environment, the more valuable an artificial reward and the less costly the sacrifice to obtain it. • Once tolerance has developed, avoiding withdrawal becomes a strong negative reinforcement.

30. 4.NATURAL HISTORY

31. Natural History “…substance abuse exacts a considerable toll on Canadian society in terms of morbidity and mortality, accounting for 21% of deaths, 23% of years of potential life lost, and 8% of hospitalizations.” Am J Public Health 1999;89:385-390

32. Drug Use Prison Treatment Natural History(of addiction over 20 year study period) • ~1/3 achieves abstinence; • ~1/3 dies prematurely; • ~1/3 cycles:

33. Natural History In other words: “…jails, institutions, and death”

34. 5. TREATMENT

35. Approaches to Treatment:

36. 5(a). CASE STUDY Opioid Addiction: a special problem

37. Opioid addiction: a special problem • 200,000 Canadians currently addicted to painkillers • Since 2005 the number of Ontarians • seeking treatment for Rx opioid abuse has DOUBLED • in Methadone Maintenance Therapy has TRIPLED

38. Opioid-related deaths in Ontario increased 242% over two decades The Globe and Mail July 7, 2014

39. Why Use Opioids? • Inherent responsiveness of the mammalian brain to Opioids • Connection to the Dopamine-mediated reward pathways • Universally produce feelings of euphoria, well-being • Easily available, ease of administration

40. “…opiate dependence is a brain-related disorder with the requisite characteristics of a medical illness.” National Consensus Development Panel on Effective Medical Treatment of Opiate AddictionJAMA, December 9, 1998;280: p.1937

41. Definitions • Opiate: “a remedy containing or derived from opium” • Opioid: “any synthetic narcotic that has opiate-like activities but is not derived from opium” • Narcotic: “an agent that produces insensibility or stupor, applied especially…to any natural or synthetic drug that has morphine-like actions” • Dorland’s Illustrated Medical Dictionary 27th Ed., 1988

42. Commonly used agents • diacetylmorphine (Heroin) injected, smoked, inhaled • morphine (MSContin, M-Eslon, Statex) swallowed, injected, inhaled • codeine (Tylenol#1#2#3#4, Atasol, CodeineContin, Lenoltec, 222) swallowed • oxycodone (Percocet, Oxycocet, Endocet, OxyContin, OxyIR) swallowed, injected, inhaled • hydromorphone (Dilaudid, HydromorphContin) swallowed, injected

43. Newer/rarer agents • butorphanol (Stadol) • meperidine (Demerol) • buprenorphine (Suboxone)* • fentanyl (Duragesic) • pentazocine (Talwin)* • propoxyphene (Darvon)* • tramadol (Tramacet, Ralivia, Tridural) *mixed agonist-antagonist

44. DSM IVCriteria for Opioid Withdrawal A Either of the following: 1) cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer) 2) administration of an opioid antagonist after a period of opioid use B Three (or more) of the following, developing within minutes to several days after Criterion A: 1) dysphoric mood 2) nausea or vomiting 3) muscle aches 4) lacrimation or rhinorrhea 5) pupillary dilation, piloerection, or sweating 6) diarrhea 7) yawning 8) fever 9) insomnia

45. DSM IV Criteria for Opioid Withdrawal C The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder

46. Treatment Options • Harm reduction→ needle exchange, substitution ↓ ↑ • Abstinence→ residential treatment, 12-step programs

47. Benefits of Substitution • Legally sanctioned, therefore socially-determined dangers of use are avoided • May bring individuals into contact with benign/beneficent social institutions

48. Initiating Treatment History: establish DSM IV criteria for dependence; underlying psychiatric comorbidity; ascertain exposure to STD’s, viruses; inquire re: physicaland/or sexual abuse Physical Examination: signs of withdrawal or intoxication; track marks and injection-related infection; stigmata of hepatitis Urinalysis: helps to establish diagnosis of opiate dependence, screens for potential dangerous interactions Other laboratory tests: HIV, HBsAg, anti-HCV, hCG, PAP, cervical and/or urethral swabs, other tests depending on indication

49. Initiating Treatment (cont’d) Treatment Agreement: includes exceptions to confidentiality, risks & benefits of MMT, expectations re: frequency of urinalysis, attendance of counseling, physician assessment, consequences of breaking agreement. Counseling: moderate other drug use to avoid overdosing during induction (especially other opiates, benzodiazepines, alcohol) safe injection practices Contraception: MMT reverses reduced fertility & oligo- or amenorrhea experienced by many female injection drug users

50. Methadone • Standard of care for over 30 years (Dole VP, Nyswander M. JAMA, 1965; 193: 80-84) • Synthetic pure  agonist • Long half-life (~24 hours) • Metabolized in liver, excreted in urine & bile • High oral availability • Reduces craving for other opiates • Blunts withdrawal symptoms • Blocks euphoric effects of other opiates