Borrowing From a Slide Show

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Borrowing From a Slide Show

• David Fiellin, MD, Yale University
• Member, Opioid Agonist Treatment Workgroup, ASAM
  
• Chair, Buprenorphine Treatment
• Sub-Workgroup
• What is Opioid Addiction Criteria, etc.
• Epidemiology Medical Complications
• How Maintenance Isnt Creating Another
  Addiction
• Effectiveness of Agonist Treatment

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Opioid Dependence An Overview

• David A. Fiellin, M.D.
• Yale University School of Medicine

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What does it mean to be opioid dependent?
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Opioid Dependence (DSM-IV)(3 or more within one
year)

• Tolerance
• Withdrawal
• Larger amounts/longer period than intended
• Inability to/persistent desire to cut down or
  control
• Increased amount of time spent in activities
  necessary to obtain opioids
• Social, occupational and recreational activities
  given up or reduced
• Opioid use is continued despite adverse
  consequences

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The Definition of Alcoholism (NCADD/ASAM)

• Alcoholism is a primary, chronic disease with
  genetic, psychosocial, and environmental factors
  influencing its development and manifestations.
  The disease is often progressive and fatal. It is
  characterized by continuous or periodic impaired
  control over drinking, preoccupation with the
  drug alcohol, use of alcohol despite adverse
  consequences, and distortions in thinking, most
  notably denial.

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Loss of Control / Preoccupation

• Impaired control means the inability to limit
  alcohol use or to consistently limit on any
  drinking occasion the duration of the episode,
  the quantity consumed, and/or the behavioral
  consequences of drinking.
•  
• Preoccupation in association with alcohol use
  indicates excessive, focused attention given to
  the drug alcohol, its effects, and/or its use.
  The relative value thus assigned to alcohol by
  the individual often leads to a diversion of
  energies away from important life concerns.

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ADDICTION

• Agents
• Biology
• Context
• Substances
• Hosts
• Environments

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Substances

• Legal Drugs (Alcohol, Nicotine)
• Illegal Drugs
• Street Drugsno / little standard medical use
• Prescription Drugsused in standard medical
  treatment, but illegal when
• obtained without a physician prescription
• not used as intended/prescribed
• dosage, frequency, route of administration

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Is it Addiction or Pseudoaddiction?

• Pseudoaddiction a syndrome of maladaptive
  behavior indicating not true addiction, but at
  attempt on the part of the patient to obtain
  relief of under-treated pain
• Preoccupation, seeking supplies, phone calls
  between refills, ER visits, and even
  doctor-shopping and securing illicit supplies,
  can indicate pseudoaddiction

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Is it Addiction or Pseudoaddiction?

• Addiction taking more meds leads to decrease in
  function
• Pseudoaddiction taking adequate dose of opioids
  improves function and ends pattern of maladaptive
  behaviors
• REMEMBER its not the medication thats
  pathological opioids are not intrinsically evil!

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Why does the brain prefer opium to broccoli?
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(No Transcript)
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Why does the brain prefer opioids to broccoli?

• Opioids are reinforcing
• Agonist activity at opioid receptors triggers
  neurochemical events
• The Mu opioid receptor is the one that medicates
  the psychoactive effect of opioids
• high affinity for enkephalins, beta endorphins,
  and opioids
• Hows it all happen?
• Mu agonist activity triggers DA release in the
  mesolimbic dopamine system
• With this, there are cellular and receptor
  adaptations
• Repeated exposure to short acting opioids is
  particularly reinforcing, leading to
  self-administration, tolerance, withdrawal,
  craving

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Changes in Neurobiology

• Repeated exposure to short acting opioids leads
  to neuronal adaptations
• Mesolimbic dopaminergic system
• adaptations in G protein-coupled receptors
• up regulation of cyclic cAMP second messenger
  pathway
• Changes
• Mediate tolerance, withdrawal, craving,
  self-adminstration
• Insight into the chronic and relapsing nature of
  opioid dependence
• Basis of specific pharmacotherapies to stabilize
  neuronal circuits

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Commonly Misused Opioids

• Diacetylmorphine (Heroin)
• Morphine (MS Contin, Kadian)
• Oxycodone (OxyContin, Percodan, Percocet)
• Hydrocodone (Lortab, Vicodin)
• Hydromorphone (Dilaudid)
• Codeine (Tylenol 3)
• Meperidine (Demerol)

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Other Commonly Misused Opioids

• Opium
• Methadone (Dolophine)
• Fentanyl (Sublimaze)
• Propoxyphene (Darvon)
• Butorphanol (Stadol)
• Tramadol (Ultram)

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Routes of Administration

• IV
• IM
• SubQ (skin popping)
• PN (snorting)
• Smoking
• PO
• SL

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Why do people muscle or skin-pop?(MetroKC.gov)

• Lots of reasons. Some people just don't like to
  inject right into a vein. Others have a hard time
  hitting their veins. For some, trying to hit a
  vein gets so frustrating that they just give up
  and shoot anywhere they can. Some do it because
  drugs absorb more slowly this way. Muscling and
  skin-popping give you less of a "rush," but the
  effects of the drug may last longer. Some folks
  don't care about the rush. They're just trying to
  keep from getting dope sick. Finally, some people
  muscle or skin pop to reduce their risk for
  overdosing. Use new clean equipment!

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Route of heroin administration
Treatment Entry Data System 1992-1997
100
75
50
25
0
1992
1993
1994
1995
1996
1997
Injection
Inhalation
Smoking
Other
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Epidemiology of Heroin Use

• 2.3 million Americans reported using heroin at
  least once per year (1998)
• 800,0001 million users of heroin at least weekly
  (1998)
• 149,000 new users (1999)
• 9.6 billion spent on heroin (ONDCP 1988-1995)
• Only 170,000200,000 receiving treatment

(National Household Survey on Drug Abuse, 1999
Office of National Drug Control Policy, 1997
SAMHSA, Office of Applied Studies, National
Household Survey on Drug Abuse, 2000 and 2001)
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Prescription opioid abuse epidemiology, US

• Emergency Department (DAWN) reports of
  prescription opioid use in 2001 total of all
  opioids, 90,000
• Reports of oxycodone abuse
• 200118,000
• 2000 10,800
• 1999 6,400
• Reports hydrocodone abuse
• 2001 21,000
• 2000 19,000
• 1999 14,000
• Reports methadone abuse 10,000
• 1994-2002, oxycodone 450 jump!
• Bottom line big street value!

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Estimated Total Number of Heroin/Morphine-Related
Hospital Emergency Department Visits by Year
(DAWN, 2002)
95,000
90,000
80,000
70,000
60,000
50,000
40,000
30,000
1999
2000
2001
1998
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
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Hawaii, heroin use

• Mexican source, black tar, widely available in
  HI, three times the price of CA.
• 7 percent of arrestees test positive for heroin
• CSAT number of adults who abused heroin
  increased from 2,660 to 8,100 between 1995-1998,
• about 300 to 400 admissions to treatment per
  year.