The United States of Drugs

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The United States of Drugs
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DetoxScience and Spirit

• Kevin Kunz M.D.
• March 4, 2005
• Lokahi Treatment Centers

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My Goals at Lokahi

• Add and integrate detoxification services
• Detox protocols, with 24/7 MD assistance
• Medical evaluation of all clients
• Cooperation/collaboration with clients PCP, and
  other care providers
• Medication review and monitoring
• Consultation, referral, training
• Team player on Hawaiis best CD Program
• Be useful, have fun, enjoy life

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Overview

• Spirit and Molecules
• What is drug detox?
• Classes of drugs, signs/symptoms of drug
  withdrawal
• Detox Options
• When to refer

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Addiction A Spiritual Problem?

• Relationship to self
• Relationship to others
• Relationship to,
• and Acceptance of, Higher Power

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Principles for the Care of the Client

• The client cannot be seen as simply his/her
  disease
• Every person achieves a unique interdependent
  relationship of body, mind, emotions and spirit
• The client and the health professional are
  colleagues
• Illness may provide an opportunity for personal
  growth
• Illness must be seen in the context of the life
  span of the individual
• See last 5 slides for expansion

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Goals of Detoxification

• To provide a safe withdrawal.
• To provide a withdrawal that is humane and
  protects the patients dignity.
• To prepare the patient for ongoing treatment of
  his/her primary addictive disease

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Principles of Detox

• Detox does not constitute treatment
• Care should be individualized
• The intensity and course of withdrawal is
  variable and not always predictable
• Use protocols of established safety/efficacy
• Control client access to drugs, and if used, use
  the lowest possible doses of Rx medications
• Client participation in Discovery and Recovery
  components ASAP

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Medical Withdrawal vs. Detoxification

• Detoxification the process of safely and
  comfortably discontinuing drugs from a patient
  who is addicted
• Medical Withdrawal the process of safely and
  comfortably discontinuing medications from a
  patient who is physically dependent

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Duration and Symptoms of Withdrawal

• Acute Withdrawal usually last than a week
  symptoms specific to drug class
• Protracted Withdrawal weeks or months symptoms
  resultant from dopamine deficiency
• ( low energy, loss of motivation mood
  disturbance, sleep disturbance, anxiety, craving
  etc.)

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Detox is a Component of Treatment

• Treatment Components
• percent duration
• Detox .001 days to weeks
• Discovery .05 weeks to months
• Recovery 95 forever

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Detox is .001 ???

• Yes, but if no successful detox, no chance for
  discovery or recovery zero detox zero
  recovery
• Detox is a major barrier to entering treatment
  help is not readily available
• Some clients can be socially detoxed
• Many clients need medicated or medically managed
  detox

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Discovery Recovery

• Discovery (5)
• Disease concept
• Insight
• Storyline
• IC, IOP, Residential
• Drug free
• Book learning

• Recovery (95)
• Humility
• Acceptance
• Openness
• Gratitude
• Service
• Spiritualality

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All drugs of abuse mimic or modify the brains
own neurotransmitter or receptor systems
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Mesolimbic Dopamine System and Drug Misuse

• Circuit 1
• LIKE
• Pleasure circuit
• Meso-accumbens
• Circuit 2
• WANT
• Desire and urge circuit
• Basolateral n. of amygdala
• Circuit 3
• Need
• Pathologic desire demand circuit
• Periaqueducal gray of brain stem

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Drug Classes

• Sedative/Hypnotics
• Stimulants
• Opioids
• Psychedelics Etc. (not today)

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Sedative/Hypnotics OTC vs. Rx
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Sedative/HypnoticWithdrawal Up We Go

• EtOh/BNZ/Barbs are CNS depressants
• Enhance GABA effect
• Inhibit autonomic adrenergic systems
• modulate dopamine in the mesolimbic system
• Abstinence or Decrease causes rebound upward
• Relative GABA deficiency leads to anxiety,
  increased psychomotor activity, seizure kindling
• Rebound sympathetic adrenergic activity leads to
  tachycardia, HBP, tremor, diaphoresis
• Time Course Acute Onset 6-72 hours
• Protracted weeks or months

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Clinical Expression of the Alcohol Withdrawal
Syndrome
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AWS Signs Symptoms
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Non-Pharmacologic AWS Rx

• Quiet supportive environment
• Educate on withdrawal process
• Adequate fluids, food
• Vitamins ( MultiVit, Thiamine)
• Off work?
• Encouragement, affirmation of courage and wisdom
  of decision
• Good person bad condition
• Engagement, begin the healing brain spirit)

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Receptor Directed Treatment
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Sedative-Hypnotic Withdrawal When to Get Help

• Hx of seizures or delirium
• Multiple drugs on board
• Significant medical or psychiatric co-morbidity
• Intolerable Type A symptoms, or Type B score /
  2 or C symptoms /1
• Pregnant
• Intuition, worried, or scared

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Stimulants

• Ice
• Cocaine
• Methamphetamine/Amphetamine (licit/illicit)
• Ecstasy
• Ephedra, Pseudoephedrine, etc.
• Nicotine, Caffeine

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Stimulants Illicit Prescription
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Medical Methamphetamine

• Schedule II Psychostimulant
• Medical use for narcolepsy, ADD, obesity
• Pharmaceutical companies were the first dealers,
  pushers

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Provigil and FDA warning

• Minimized CNS effects and abuse potential
• Promoting for unapproved uses energy, fatigue,
  tiredness
• Actually produces psychoactive and euphoric
  effects and feelings similar to Ritalin
• false, lacking in fair balance, or otherwise
  misleading..

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Stimulants Up We Go

• Short-term effects euphoria, well-being
  energy, hyperactivity talkativeness anorexia
  dry mouth nausea BP,HR up focus
• Long-term effects sleep problems mood swings
  compulsiveness/repetition paranoia, panic,
  anxiety, seizures, dependence/addiction
• Anytime effects psychosis hallucinations
  paranoid delusions violence

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All Stimulants Can Cause
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Stroke
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Ice Self-Reported Problems

• Chest pain 30
• Headaches 43
• Seizures 2
• LOC 8
• Need Rx 11

• Previous Psych Rx 14
• Depressed a lot 19
• Suicidal thoughts 7
• Hallucinations 35
• Paranoid thoughts 29

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Stimulant Withdrawal - Down We Go

• Acute 3-10 days
• Fatique
• Hunger
• Deep Depression
• Disturbed sleep, headaches
• Irritability
• Agitation and anxiety
• Protracted weeks, months
• low energy
• loss of motivation
• mood disturbance, paranoia
• sleep disturbance
• anxiety, craving etc.

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Non-Pharmacologic Rx for Stimulant Withdrawal

• Quiet supportive, drug-free environment, sleep
• Acknowledge that WD is difficult, distressing
• Educate on withdrawal process
• Adequate fluids, food
• Safety
• Off work?
• Encouragement, affirmation of courage and wisdom
  of decision
• Good person bad condition
• Engagement, begin the healing brain spirit

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Pharmacologic Rx for Stimulant Withdrawal

• Zyprexa
• Wellbutrin
• Anti-anxiety agents
• Symptomatic medications
• No Protocols Available

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Is this really a new problem?

• 1 in 200 Americans either cocaine
  or opium addicted
• 2003 hydrocodone 1 prescribed
  drug in America

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Drug
2003 Rx
Revenue

• Hydrocodone 74-84M
• Lipitor 69M 6.7B
• Synthroid 49M
• Norvasc 36M
• Zoloft 33M 2.9B
• Toprol XL 30M
• Zocor 29M 4.9B
• Prevacid 28M 4B
• Amoxicillin 27M
• (Others in the top 130 Xanax, Ambien, Ativan,
  Klonipin, Soma
• Valium, oxycodone, Oxycontin, Darvocet, Ultracet,
  Concerta, Adderal)

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DEA Production Quotas,1990-2000

• Morphine 300
• Hydrocodone 500
• Hydromorphone 600
• Oxycodone 1200
• Fentanyl 1700

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Prescribed Opioids In Hawaii(Source K. Kamita,
Chief, NED, State of Hawaii. 11/7/03)

• Drug
• APAP/hydrocodone
• Tussionex
• Endocet
• OxyContin
• Morphine sulfate
• Methadone

• Dosage Units
• 2,310,398
• 564,258
• 561,658
• 506,408
• 335,502
• 326,446

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Opioids Illicit vs. Prescription
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Opioid Drug Classes

• Agonist
• Relieve pain and alter mood. Morphine,
  hydrocodone, fentanyl, tramadol, propoxyphene,
  codeine, etc.
• Antagonist
• Displace or block opioids from receptors, no mood
  altering effect. Naloxone, Naltrexone
• Mixed agonist/antagonist
• Have both agonist and antagonist actions.
  Buprenorphine (Suboxone), Stadol, Talwin

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.morphine molecule
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.opioid receptor model

• .
• .

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Opioid Withdrawal

• Acute
• Autonomic
• Rebound increased NE activity from locus
  coeruleus
• Increase BP, HR, peristalsis, diaphoresis, CNS
  irritability, etc.
• Affective
• Suppressed in the dopaminergic reward pathways
• Depression, anxiety, anhedonia, craving, anergia
• Protracted
• 3-6 months or longer
• Anxiety, insomnia, craving, cyclic changes in
  wgt, pupil size

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Acute Opioid Withdrawal

• 5-7 days in length
• Runny nose, sneezing,
• sweating, yawning,
• restless, insomnia
• Piloerection, twitching,
• myalgia, arthralgia,
• abdominal cramps
• Tachycardia,fever,
• hypertension,tachypnea,
• anorexia, diarrhea,
• vomiting, dehydration

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Protracted Opioid Withdrawal

• Anergia
• Ahedonia
• Sleep disturbance
• Emotional lability/dysphoria
• Stress incompetence
• Craving
• Can persist for months

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Opioid Detoxification Options

• Ultra-Rapid Detox (not in Hawaii)
• Naltrexone induced, hospital setting
• Licensed methadone clinic (detox or maintenance)
• Symptomatic medications
• Clonidine, NSAID, Vistaril, Robaxin etc. high
  fail rate
• Subutex/Suboxone (detox or maintenance)
• Still need Rx for primary disease of addiction

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Buprenorphine

• Opioid agonist/antagonist. Low diversion risk.
• Replacing methadone in France, ? US
• Excellent safety profile, decades of experience
  as IM-IV-SL analgesic. MDs now Rx for pain.
• FDA approved for opioid detox or maintenance
• Formulated as Subutex, and Suboxone -naloxone
  added to deter IV use, diversion
• Being used in addiction,dependence,pain
• MDs can acquire DEA OK CME required

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Bup Diss curve
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PAU
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Principles for the Care of the Person

• The patient cannot be seen as simply his/her
  disease
• Every person achieves a unique interdependent
  relationship of body, mind, emotions and spirit
• The patient and the health professional are
  colleagues
• Illness may provide an opportunity for personal
  growth
• Illness must be seen in the context of the life
  span of the individual

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The patient cannot be seen simply as his/her
disease

• ..Neither can the health professional limit
  his/her care to medical technology. The full
  healing potential of their relationship often
  depends on their interaction as whole human
  beings, and far exceeds the treatment of disease.

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Every person achieves a unique interdependent
relationship of body, mind, emotions and spirit

• inseparable from other individuals and
  society. Illness can best be understood as a
  disturbance within the dynamic balance of these
  relationships. Health may be defined as the
  harmony of the whole, and the work of the health
  professional as aiding in the reestablishment of
  a more fully conscious equilibrium within the
  whole.

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The patient and the health professional are
colleagues

• their collaboration activates the latent
  human and biological resources within the patient
  for healing. The patient is encouraged to be
  aware of his/her choices and to become
  increasingly responsible for his/her own health,
  growth and fulfillment.

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Illness may provide an opportunity for personal
growth..

• the experience of disease may be used
  creatively to re-evaluate life goals and values,
  provide clarity in setting priorities and to
  mobilize previously untapped strengths. The
  health professional enables the patient to evolve
  a positive value from the experience of disease,
  to maintain identity, and to reaffirm his/her
  dignity as a person.

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Illness must be seen in the context of the life
span of the individual..

• Indeed, it may have a unique meaning when seen
  in reference to the total life of the patient.
  Physical disease and emotional suffering have an
  individual message for each patient, yielding
  information about such personal issues as
  lifestyle, self-worth and value of time. The
  knowledge gained through the understanding of
  this individual meaning may enable the patient to
  enrich the quality of his/her life.