New and Old Medications for the Treatment of Substance Dependence

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New and Old Medications for the Treatment of
Substance Dependence

• Barry Zevin MD
• Tom Waddell Health Center San Francisco
  Department of Public Health
• Harm Reduction Therapy Center, San Francisco, CA
• Barry_Zevin_at_sfdph.org

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Ways of Understanding Addiction

• Crazy, Lazy, and Bad - Moral model
• Tail of the bell curve - Statistical model
• Youve got issues - Psychological model
• Self Treatment - Psychiatric model (Self
  treatment of psychiatric disorder)
• In the wrong place at the wrong time with the
  wrong people - Social model
• Its a disease - Medical model
• Its an emptiness that you need to fill up -
  Spiritual model

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Bio-Psycho-Social-Spiritual model

• Biological phenomenon underlie all aspects of
  addiction and addictive behavior
• Psychological, Social, and Spiritual issues are
  all facets of the illness of addiction
• The moral model is still the prevalent way of
  understanding addiction
• This understanding is damaging to patients,
  families, and society
• Better understanding of the neurobiological basis
  of addiction can help reverse this

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Evidence for Addiction as a neurobiological
phenomenon

• Strong genetic predisposition
• Excellent evidence from animal studies
• Brain changes visible on imaging, functional
  imaging, and pathological exam
• Addiction is a chronic relapsing disorder very
  similar to well accepted diseases such as
  hypertension, diabetes, or asthma

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Important neuro-biology concepts

• Reward systems - dopamine
• Homeostasis
• Neuro-Inhibition / neuro-excitation - GABA -
  glutamate system
• Multiple brain systems involved - opioid,
  cannabinoid, nicotinic acetylcholine , others
• Physical dependence / withdrawal / reward
  deficiency
• Craving / relapse re-exposure to drugs (cross
  triggering), cue induced, stress induced

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Important neuro-biology concepts

• Neuroplasticity
• Vulnerabilities to addiction
• Inherited, acquiredmixed
• Genetic connection established
• Very few instances in which actual genetic
  changes have been identified
• Co-occurring disorders very common
• Set and setting very important
• Spiritual components critical

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Reward circuits

• Addictive drugs directly or indirectly work
  through reward circuits
• Activity in reward circuits over-stimulated and
  therefore natural activity reduced (possibly
  permanently damaged)
• Reward circuits are stimulated not only by actual
  exposure to drug but by cues, stress, exposure to
  other drugs
• This is part of natural functioning of system

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Craving and Loss of Control

• Dopamine reward systems are the primary
  motivating system in the brain
• Medication interventions based primarily in the
  dopamine system not effective

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Craving and Loss of Control

• Drug craving glutamate system and
  norepinephrine cause dopamine release in
  anticipation of remembered conditioned reward
  primes the pump and triggers all the compulsive
  behaviors and motor memory in anticipation of
  further dopamine release
• Endorphin, Endocannabinoid, Gaba, etc. systems
  all have complex interconnections acting on this
  phenomenon

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Craving and Loss of Control

• Real problem in addiction medicine is relapse
• Effective medication treatments for addiction
  depend on understanding and changing the complex
  neurobiological systems related to craving and
  loss of control

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Case 1 Alcohol
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Mr. Stevens

• Mr. Stevens
• 45 yo homeless man with long history of drinking
  with consequences including falls with fractures,
  incarceration for offenses including indecent
  exposure (resulting in being listed as a sex
  offender), violent and abusive episodes resulting
  in his being 86d from many clinics and sites,
  suicidality requiring involuntary holds.
• He has had multiple treatment episodes usually
  beginning with inpatient detoxification. He is an
  enthusiastic AA participant when sober but
  usually relapses in 3-6 months often with severe
  consequences
• Triggers for relapse include relationships,
  attempting to work, being discouraged by mess
  Ive made of my life, walking by liquor store,
  seeing others drink, etc.

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Case 1 Mr Stevens

• Obnoxious, abusive and violent when drinking
• Anxious, guilty, dependent when not drinking
• Interventions
• BZD Rx resulting in early alcohol relapse, SSRI
  described as helpful but not adherent after early
  relapse
• 18 mo ago started naltrexone 50mg PO, citalopram
  added
• Initially maintained 6 mo abstinence in dry bed
  in HL shelter then given opportunity for
  residential dual diagnosis program or SRO based
  minimally supportive housing - chose housing,
  relapsed, eviction due to out of control behavior
  after 4 months

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Case 1 Mr Stevens

• Returned to clinic 1 month after eviction with 1
  week clean and sober staying in HL shelter.
  Restarted Naltrexone and entered residential
  program when available. Now struggling with
  program ending and continued homelessness
• 15 months not drinking in the last 18 months is
  by far longest period of abstinence for patient
  since adolescence. Despite exposure to usual
  triggers for relapse has been better able to cope
  with craving
• Anxiety, personality style, multiple losses and
  traumas, major barrier of sex offender
  registration are still problems

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Treatment

• Research shows that some medications may be
  helpful
• Decreasing craving
• Decreasing amount of drinking in individual
  episodes and over the course of time
• Help maintain abstinence
• All medications may work best combined with
  psycho-social-spiritual modalities

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Best Practices for Alcohol Dependence

• Diagnose and treat underlying mental health
  disorders
• Evidence for efficacy in treatment of virtually
  all MH disorders is superior to any modalities
  for alcohol dependence
• Symptoms caused by direct effect of alcohol
  should improve within 1-2 weeks

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Best Practices for Alcohol Dependence

• Diagnose and treat underlying mental health
  disorders (cont.)
• Depression/anxiety/bipolar disorder/personality
  disorders commonly co-occur
• Use principles of harm reduction psychotherapy
• Use meds with consideration of safety when used
  with alcohol
• Most meds are safe even if drinking
  resumes/continues
• Caution with BZDs due to synergistic risk of
  oversedation
• Caution with hepato-toxic meds in patients with
  alcoholic hepatitis

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Promising Target Mechanisms for Alcoholism
Treatment

• Prevent brain damage from repeated episodes of
  withdrawal (excito-toxicity)
• Prevent priming effect of small amounts of
  alcohol from triggering full blown relapse
• Prevent conditioned alcohol related stimuli
  (cues, environmental context from triggering
  relapse)
• Prevent stress and negative affect from
  triggering relapse
• Reduce impulsivity

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Goals of Medication treatment for Alcoholism

• Prevent adverse effects of withdrawal
• DTs, seizures, severe anxiety and dysphoria
• Excito-toxicity and cognitive damage
• Early exit from treatment
• Abstinence maintenance / Relapse prevention
• Moderation / Prevention of loss of control

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Alcohol Medication Treatment

• Withdrawal-BZD preferred
• Adjunctive medications for symptom control
• Added meds especially when co-occurring disorders
• Use symptom triggered dosing protocol when
  possible (use CIWA scores)
• Fixed protocols more practical and successful for
  outpatient (or poorly staffed/poorly trained
  residential or hospital) detox

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Alcohol Medication Treatment FDA approved for
treatment of alcoholism

• Naltrexone
• opioid receptor antagonist, blocks
  reward/reinforcement from drinking Blocks
  anticipatory reward from triggers/cues
• Best evidence so far - Shown to statistically
  reduce drinking days, volume of drinks, increase
  time to first drink and abstinent days compared
  to placebo
• Start as early as possible after initiation of
  abstinence
• 50mg once daily by mouth
• 1/4 great effect, 1/2 works somewhat, 1/4 no
  effect (anectdotal)

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Alcohol Medication treatment

• Naltrexone
• Compliance a problem dysphorogenic
• Cannot use in patients requiring opioid
  medication for chronic pain or Methadone/Bupe pts
• Injectable long acting form not available to poor
  people due to drug company marketing strategy
• If patients need acute pain control (car crash or
  emergency surgery need special attention to
  overcome opioid receptor blockade)

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Alcohol Medication Treatment

• Disulfiram (antabuse)
• Alcohol use results in build up of acetaldehyde,
  causing unpleasant nausea, vomiting, flushing and
  headache
• Works best if given under supervision with strong
  social support to take it everyday
• Possible positive effects on cocaine addiction
  may make this a good choice for combined alcohol
  / cocaine
• Need to be alcohol free for 72 hours
• 250mg by mouth once daily
• Check liver enzymes during therapy

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Alcohol Medication treatment

• Acamprosate
• indirectly blocks glutamate effect at NMDA
  receptor, offsetting GABA/glutamate system
  imbalance
• Reduces chronic withdrawal symptoms, and
  reduces cue related relapses
• Good safety profile, well tolerated
• Two 333mg tablets three times daily by mouth
• Disappointing results in recent large American
  trials compared to naltrexone alone and placebo
• Worth a try especially in patients with no effect
  with naltrexone or who have contraindications
• May work better in patients with longer periods
  of continuing abstinence

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Alcohol Medication Treatment FDA approved for
indications other than alcoholism

• Topiramate
• anticonvulsant, stimulates GABA b receptor in
  reward circuit and reduces dopamine release with
  alcohol use, limiting reward
• Also offsets GABA/glutamate system imbalance and
  reduces chronic withdrawal symptoms
• Reduces drinking days, drinks per day, increases
  time to first drink and abstinent days
• 25mg to 300mg daily need to increase dose slowly
  to avoid cognitive dysfunction - initial dosing
  while drinking ok
• Not too easy a drug to use, expensive
• Worth considering especially for patients with
  co-occurring migraines, seizures, bipolar, morbid
  obesity, neuropathic or other pain syndromes

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Alcohol Medication Treatment

• FDA approved for indications other than
  alcoholism
• Valproate (Depakote), Levaricetam (Keppra) other
  AEDs may be worth trials in special
  circumstances
• Baclofen
• Also promising in cocaine and other addictions
• Prazosin and other alpha blockers
• Also used for PTSD related nightmares / sleep
  disorders
• Ondensetron
• In trials was effective in early onset
  alcoholics/high heritability
• Other serotonin active meds may not be effective

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Alcohol Medication Treatment

• What about Benzodiazepines?
• Risk of overdose
• Risk of triggering drinking in abstinent patients
• Can be life changing in selected patients with
  severe underlying anxiety not responsive to other
  meds.
• alcohol maintenance strategies
• Positive outcomes in research done in Canada with
  severe alcoholics with this approach

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Best Practices for Alcohol Dependence

• Role of AA / 12 step facilitation
• AA is a spiritual program not a medical
  intervention
• Recommendations to go to AA may be reasonable
  but do not constitute medical care
• 12 step facilitation is an accepted medical
  intervention
• Research shows it to be equally as good/bad as
  other interventions
• MATCH Study
• Medication treatment for alcoholism and AA are
  not in conflict
• See brochure The A.A. Member - Medications
  Other Drugs and p. 133 the Big Book

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Tobacco

• Most alcohol and drug users will get sick and die
  of tobacco related illnesses
• Classic harm reduction situation in which the
  active drug, nicotine, is not responsible for the
  harms attributable to the substance
• Smoking cessation should be a very high priority
• Quitting while still using is possible
• Smoking cessation counseling may be strong signal
  that you have hope and caring for a patient
• Quitting is possible and desirable even for
  people with severe co-occurring addictions and/or
  severe mental health disorders
• Quitting cigarettes may be highly motivating
• Moderation and reducing use may be helpful
• Residential programs that prohibited smoking and
  offered smoking cessation treatment had better
  results for smoking cessation and alcohol and
  drug related outcomes

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Tobacco

• There are excellent medical treatments to help
  with smoking cessation available
• All treatments work best combined with
  psycho-social techniques
• Quitting is possible and desirable even for
  people with severe co-occurring addictions and/or
  severe mental health disorders

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Pharmacotherapy Nicotine

• Very difficult addiction to manage up to 75 of
  smokers want to quit, 33 try to quit each year,
  3-5 succeed
• One pack per day smoker gets 200 doses of
  nicotine per day pairing of drug use to multiple
  daily life events
• Unique ability to modulate wide variety of moods
• Oral gratification
• Causes weight loss
• Any type of pharmacotherapy doubles rate of
  success

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Pharmacotherapy Nicotine

• Nicotine replacement therapy low tonic dose of
  nicotine increases number of nicotinic
  acetylcholine receptors in desensitized state
  reduces withdrawal symptoms
• Number of receptors slowly decreases over weeks

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Pharmacotherapy Nicotine

• Nicotine replacement must be given at high enough
  dose
• Patients with chronic schizophrenia appear to
  have a positive effect of nicotine on associated
  cognitive declines
• Consider indefinite nicotine replacement in these
  patients
• This may be true for many smokers and paradigm is
  changing toward long term / indefinite nicotine
  replacement

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Pharmacotherapy Nicotine

• Nicotine gum 2-4mg chew then park allows
  self-titration to symptoms 10-15 pieces per day
• Ineffective use (continuous chewing) often a
  problem
• mouth irritation / poor dentition may limit use
• Nicotine patch
• 7-21mg change every 24 hours
• 1PPD often require more than one patch - under
  dosing is main cause for failure
• consider dose taper no sooner than four weeks
  long term use is acceptable
• if sleep disturbance can remove at bedtime
• adhesive irritation may limit use
• Nicotine nasal spray or inhaler (ok to combine
  with patch)
• Safe even in patients with coronary artery disease

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Pharmacotherapy Bupropion

• Bupropion monocyclic antidepressant, inhibits
  reuptake of dopamine and norepinephrine does not
  work by its anti-depressant effect
• Antagonizes nicotinic acetylcholine receptors and
  decreases reward of smoking
• Additive effect with nicotine replacement therapy
• Minimizes weight gain
• 150 mg by mouth daily for three days, then twice
  daily
• Cannot be used in patients with history of
  seizures
• May be useful in stimulant abuse - aim to quit
  cigs and coke or speed

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Pharmacotherapy Verenicline

• Chantix (varenicline) partial agonist at
  nicotinic acetylcholine receptor occupies
  receptor and reduces/eliminates reward of smoking
  while reducing withdrawal symptoms
• .5mg daily for three days, then .5mg twice daily
  for five days, then 1mg twice daily starter kit
  available
• Better than bupropion and/or nicotine replacement
  therapy
• Major side effects are nausea, headache and
  insomnia
• Can be used in combination with most other meds
• Concerns about mood changes and suicidality
• Careful monitoring for depression / suicidality
  throughout treatment course (this is a good idea
  for everyone making a quit attempt)

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Case 2 Opioid Dependence
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Miss Daniels

• 30 yo homeless woman with hx of childhood trauma,
  MDD, GAD, chronic pain, Hep C, and heroin
  dependence
• Started using IV heroin in adolescence, now uses
  1-2 gms daily
• Presented with desire to stop using, had multiple
  attempts but not able to maintain abstinence.
  Tried methadone detox in past. Cited addiction to
  the ritual of using and being in pain as reasons
  for not being able to stop
• Never received tx for depression and anxiety in
  past
• Difficult to form relationship with providers due
  to trust issues

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Case 2 Ms. Daniels Progression of Treatment

• Developed relationship over time. Sporadic visits
  eventually became weekly visits
• Slowly introduced other tx providers
• Tried various antidepressants/antianxiety/mood
  stabilizer medications (Paxil, Wellbutrin,
  Effexor, Klonopin, Celexa, Lamictal)
• Referred to methadone maintenance program,
  advocated for free slot until medical benefits
  approved
• Stabilized on methadone but increased crack and
  BZD use due to high level of access and triggers
  at methadone clinic
• Currently chips when excessively bored or
  stressed, ritual of use still powerful trigger

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Case 2 Ms. Daniels Progression of Treatment

• Assisted her in obtaining a companion pet (cat)
• Current medication regimen Seroquel 100mg bid,
  Remeron 15mg qhs, Trileptal 300mg bid
• Stabilized in traditional methadone clinic and
  now transferred to OBOT (office based opioid
  treatment) model combining primary care and
  addiction treatment
• daily dosing at pharmacy has resulted in much
  less other drug use
• Goals of reconnecting to family, getting
  extensive dental work done are completed.
  Orthopaedic follow-up to address sequelae of
  multiple old traumas pending, hep C treatment
  still on the back burner

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Opioid use Disorders - Natural History

• High mortality rate
• Is there a difference between heroin addiction
  and Rx opioid dependence?
• Rate of long term abstinence without methadone or
  Buprenorphine maintenance lt 10-20
• Due to congenital condition, or something caused
  by drug exposure, natural opiate receptors may be
  permanently malfunctioning
• Without methadone or Buprenorphine replacement
  relapse to opioid abuse occurs in 80 no matter
  what other kinds of treatment are done
• To feel normal most people with opioid
  dependence probably need some constant opioid
  activity on the receptor
• Buprenorphine (and probably methadone) have a
  potent effect on the psychological aspect of
  addiction. Thinking about getting high, dreams,
  craving

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Pharmacotherapy Opiates

• Endogenous opiate pathways chronically (?
  permanently) altered
• Dysphoria, chronic withdrawal symptoms, craving
• Repeated use of short acting opiates alternating
  with episodes of withdrawal drives increased
  tolerance and dysfunction of system
• Chronic use of opiate agonists at a steady level
  regulate this dysfunction back to normal

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Detox?

• One year recovery rates after opiate detox
• drug free 5-30
• Naltrexone 10-20
• Opioid agonist therapy 50-80
• Mortality much lower in currently treating
  methadone or buprenorphine maintenance then in
  waiting list or dropped out of treatment
• Be realistic and think critically of any detox
  based approach
• Respect patient choices
• Consider harms and benefits

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Pharmacotherapy Opiates

• Naltrexone mu receptor antagonist blocks
  rewarding effect of opiate use
• Must be drug free for 1-7 days or precipitate
  withdrawal
• Dysphorogenic early drop out a problem depot
  form available
• Opiate analgesics for pain control inhibited
• Efficacy in highly motivated patient with very
  strong social support
• Usually ineffective and theory of blocking opiate
  high eventually resulting in extinguishing
  craving is probably wrong
• More effective for alcohol dependence, negative
  results for cocaine but 1 positive study for
  methamphetamine

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Pharmacotherapy Opiates

• Mu receptor agonists methadone and buprenorphine
• Significantly reduce rate of mortality, IV drug
  use, crime, HIV infection, relapse increase rate
  of employment, health parameters and social
  function

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Pharmacotherapy Methadone

• long acting, once a day supervised/unsupervised
  dosing low abuse potential
• Dose titrated to reduce or eliminate withdrawal
  symptoms, craving restore physiologic functions
  toward normal
• Prolongs QT interval and risk for fatal cardiac
  arrhythmia in some patients
• Role of screening and follow up EKG causing
  controversy

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Pharmacotherapy Methadone

• Minimal sedation constipation decreases libido
• Risk of sedation low when used at appropriate
  dose and not in combination with other meds
• Danger of overdose in poly-drug use combinations
  with other sedating meds or drugs
• In USA legally only for use in treatment of
  opioid dependence in stringently regulated
  narcotic treatment programs
• Extensive street mythology may discourage use -
  No effect on bones or teeth, not worse withdrawal
  then other opioids (longer though), not really an
  effective opioid blocker, enviable long term
  safety record for methadone and opioids in
  general.

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Pharmacotherapy Buprenorphine

• Approved in 2002 can be administered in office
  setting by qualified physician no more than 30
  patients (up to 100 with request)
• Partial mu receptor agonist, will precipitate
  withdrawal syndrome in heroin or methadone users
  drug free 12-72 hours before starting depending
  on opioid abused
• Combined with naloxone to prevent IV use bitter
  taste of naloxone inhibits multiple dosing
• Equally effective as moderate doses of methadone
  (60mg/day) may not be as effective as higher
  doses of methadone (80mg/day) in patient with
  high tolerance
• This may be more related to difficulty of
  induction in these patients than tolerance levels

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Buprenorphine

• Generally safer in terms of overdose risk than
  other opioids
• Partial agonist/ceiling effect
• Overdoses that have occurred have been when used
  together with Benzodiazepines
• Level of risk still not clear
• Pharmacokinetic vs pharmacodynamic vs other
• Overdoses in abuse settings usually with IV BZD
  and / or IV buprenorphine use
• Thought to be safe in setting of prescribed BZD
  use without abuse
• With careful monitoring
• Counsel and educate all patients about risk of OD
  with BZD

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Buprenorphine and Benzodiazepine issues

• Work with patient to understand their pattern of
  BZD use
• Often used as 2nd best choice when preferred
  opioid is not readily available
• Often used to come down from cocaine or speed run
• Sometimes used for self treatment of underlying
  anxiety disorder or intolerable trauma issues
• Less commonly used to Just get high or snowed
• Danger of overdose with illicit opioid and BZD
  definitely higher than with Bupe and BZD
• Danger of OD probably higher with methadone and
  BZD than Bupe and BZD
• Liability concerns (which are not trivial)
  underlie much of the discussion

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Overdose Prevention

• Education beneficial in preventing overdose
• Naloxone training when widely offered in
  community saves lives
• Rescue breathing, naloxone kit dispensed,
  mechanism to replace when used
• Opioid users frequently exist in tight knit
  urban ecosystems and therefore training must be
  focused on active users or those likely to become
  active users
• Treatment programs are excellent settings to
  offer this service
• Most users will return to using or at least to
  spending time with using community

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Case 3 Stimulant Use Disorders
methamphetamine/cocaine
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Case 3 Mr. Player

• 40 yo homeless man with history of post traumatic
  arthritis, psychosis diagnosed as paranoid
  schizophrenia, crack cocaine use
• Previous medical provider cut him off
  prescriptions for tylenol 3 due to poor
  adherence to appointments, urine toxicology
  showing cocaine but no codeine, frequent criminal
  justice problems
• Patient agreed to enter outpatient dual diagnosis
  treatment as condition to consider restarting
  opioid analgesic for pain. Baclofen was
  prescribed as an adjunct for both muscle spasm
  and cocaine dependence

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Mr. Player Current Clinical Picture

• Patient has demonstrated
• much reduced psychotic symptoms, better clinic
  appointment adherence
• no further incarcerations
• only 1 positive urine toxicology in past year (he
  has requested that these be done as a help to his
  treatment)
• his pain and functioning are much improved on a
  moderate monthly dose of vicodin
• Patient attributes much of improvement to
  baclofen
• He continues with difficult behavior in the
  clinic especially with female staff

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Cocaine / Use Disorders - Natural History

• Genetic predisposition
• Method of delivery of drug very addictive
• Typical pattern of use - binge (run), crash,
  craving, long term persistence of intense craving
  brought on by triggers
• Theory of kindling- like a seizure
• Not everyone uses in typical patterns
• No proven medications but possibly some things to
  try
• Numerous medications studied and failed
• Baclofen, disulfiram, bupropion, several
  stimulant like drugs, atypical anti-psychotics,
  and AEDs with early promising data
• Esp. if co-occurring medical or psychiatric
  conditions

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Methamphetamine

• Chronic methamphetamine use often has severe and
  long term consequences on brain functioning
• Recognize long lasting / frequently recurring
  psychosis as a risk of methamphetamine use
• Good evidence for a genetic vulnerability to this
  adverse effect
• Recurrence may be caused by small doses or
  stressful events
• Push and crash phenomenon is common so using to
  counteract fatigue is a bad idea
• No proven medications but possibly some things to
  try
• Wellbutrin or other non SSRI antidepressants
• Stimulant or stimulant like meds being researched
• Underlying ADHD may be common but is hard to
  diagnose and treat while patients are still using
• Treating agitation and psychosis while using -
  BZD may be safest. Treating lingering psychosis
  with anti-psychotic medications may be helpful

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Pharmacotherapy Cocaine/Amphetamines

• Multiple medication trials ssris, tricyclic
  antidepressants, mao inhibitors, naltrexone,
  campral, anticonvulsants none better than
  placebo
• Baclofen, disufiram, bupropion,
  psycho-stimulants, atypical anti-psychotics,
  naltrexone, others promising in small trials but
  so were the other meds that failed in larger
  trials
• Intense psychosocial treatment
• ? Immunotherapy vaccination producing antibodies
  against drug, prevents it from reaching reward
  center

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ADHD and stimulant use (and other drug use)

• Co-occurring substance use disorders now known to
  be frequent in ADHD
• Early and continued psycho-stimulant treatment
  reduces substance use disorders
• In patients with convincing clinical history and
  presentation trial of treatment with
  psycho-stimulant or non stimulant Rx may be
  warranted
• Anecdotally in my patients abuse / diversion has
  not occurred possibly due to high access to
  cocaine and methamphetamine

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Marijuana

• The brain and body have an extensive
  endo-cannibinoid system (10X more extensive than
  endorphin system)
• There is a typical withdrawal syndrome from heavy
  marijuana use
• There is legitimate concerns re long term brain
  effects
• Increased risk of schizophrenia in small number
  of early users
• Increase in psychotic symptoms in users with
  underlying psychotoc disorders
• Brain cortex changes in long time heavy users
• Medical marijuana use has extensive pros and cons
  and these should be discussed
• Cannibinoid system primarily used for novelty and
  saliency (making things interesting)
• Possible drawbacks of virtual novelty
• Medications that block cannibinoid receptors are
  likely to have a lot of side effects
• Main proven harm of MJ use remains risk of
  involvement in criminal justice system

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Marijuana for Harm reduction

• Can marijuana work as harm reduction for alcohol
  / other drugs
• Research is lacking in this area
• Individualize decision making
• Alcoholic with severe cirrhosis MJ is greatly
  preferable to alcohol
• MJ in pt with schizophrenia and crack dependence
  maybe not (esp. if pt is already obese)

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Thank you to Esker-D Ligon NPPsychiatric Nurse
PractitionerHarm Reduction Therapy
CenterClinical facultyUCSF School of Nursing

• For valuable contributions to an earlier version
  of this presentation

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Thank You to All My Colleagues at Tom Waddell
Health Center and Our Many PartnersThank You to
My Patients Who I Learn From Every Day