Making Sense of Addiction The Continuum: Use/Abuse/Dependence/Legal/Ilegal

1. Making Sense of AddictionThe Continuum:Use/Abuse/Dependence/Legal/Ilegal James Finch, MD NC Society of Addiction Medicine NC Governor’s Institute on Alcohol and Substance Abuse Changes By Choice, LLC Durham, NC

2. PSYCHOACTIVE DRUGS OF ABUSE Nicotine Alcohol Marijuana and hashish Cocaine, amphetamines, MDMA (“ecstasy”) Heroin, opioid analgesics (pain pills) Benzodiazepines, barbituarates Inhalants (solvents, gases, nitrous) Hallucinogens (LSD, mescaline, psilocybin) Other: Ketamine/PCP/DXM/steroids NEXT?

3. Deaths Related to Drug Use(US Centers for Disease Control and Prevention) tobacco >430,000/year alcohol 100,000/year illicit drugs 15,000/year abuse of Rx meds escalating

4. Commonly Abused Prescription Medications Ranking of common classes of abused prescription medications in terms of frequency and public health impact: Opioid analgesics Hydrocodone (Vicodin) Oxycodone (Percocet, Oxycontin) Methadone (Dolophin) Benzodiazepines Alprazolam (Xanax) Clonazepam (Klonopin) Stimulants Amphetamine (Adderal) Methylphenidate (Ritalin)

5. US Therapeutic Opioid Use 15,000 Oxycodone Hydrocodone 12,000 Morphine Methadone 9,000 Grams/100,000 people 6,000 3,000 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 5 Manchikanti L, Singh A. Pain Physician. 2008;11(2 Suppl):S63-S88.

6. Psychotherapeutic Agents: Increasing Non-medical Use 2,500 Pain relievers 2,000 1,500 New Users, thousands Tranquilizers 1,000 Stimulants 500 Sedatives 0 1965 1970 1975 1980 1985 1990 1995 2000 6 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2001 National Household Survey on Drug Abuse. 2002. http://www.oas.samhsa.gov/nhsda/2k1nhsda/vol1/CHAPTER5.HTM#fig5.3. Accessed April 23, 2008.

7. Trends In Emergency Department Mentions

8. Epidemics of Unintentional Drug Overdose Deaths in the US: 1970-2006 Prescription drugs Crack cocaine Heroin Len Paulozzi, MD, MPH National Center for Injury Prevention and Control Centers for Disease Control and Prevention

9. Unintentional Deaths in NC Due To Prescription Drugs Source: NC State Medical Examiner’s Office

10. New Illicit Drug Use in US: 2006 2,500 2,150 2,063 2,000 1,500 1,112 New users, thousands 977 1,000 860 845 783 500 267 264 91 69 0 Marijuana Cocaine Stimulants Sedatives Heroin PCP Pain Relieversa Tranquilizers Ecstasy Inhalants LSD a 533,000 new nonmedical users of oxycodone aged ≥12 years. Past year initiates for specific illicit drugs among people aged ≥12 years.LSD, lysergic acid diethylamide; PCP, phencyclidine.Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2006 National Survey on Drug Use and Health. Department of Health and Human Services Publication No. SMA 07-4293; 2007. 10

11. We Are a Drug Using and Abusing Culture Alcohol Tobacco Caffeine and other stimulants Sedatives Tranquilizers Analgesics/pain pills Illicit drugs

12. A Long Cultural Tradition of Seeking Relief with Medication “to lull all pain and anger and bring forgetfulness of sorrow…” Homer: The Odyssey JWF: The Vintage Image Gallery

13. Drugs Use Extends Along a Continuum from Low Risk Use to Abuse and Dependence PROBLEMS Dependence 5% None 35% At-risk 8% Moderate 45% Abuse 7% USE Alcohol use in primary care patients > 18 years old A Guide to SA Services for Primary Care Clinicians, SAMHSA, 1997

14. Why do people start using drugs? To feel good: get “high” or “buzzed”or“altered” To avoid emotional pain, relax or deal with stress: “chill” or “mellow out” To perform better, activate, energize or enhance: “rev” or “amp up” To be part of a group, socialize, conform: “fit in” Medical treatment of physical pain or psychiatric illness: “get relief”

15. Why do people keep using or escalate their use of drugs? Previous reasons with expansion into other domains Narrowing of behavioral alternatives/increased reliance on drug Maintaining “hedonic tone” Avoiding physical withdrawal What’s “good” about using seems to outweigh what’s “not so good” Denying or ignoring risk or problems

16. Types of Risks Associated with Drug Abuse Too much for too long risk: The more and the longer you use, the more likely you are to have problems. Ex: Alcohol and liver disease Marijuana and lung disease Any use at all risk: The characteristics of the drug or how it is used mandate risk at any level of use. Ex: Cocaine and cardiac risk Injecting behaviors and infectious disease risk Drinking/drug use and trauma risk

17. Risks Associated with Prescription Medication Abuse • Cognitive and/or psychomotor impairment • Danger of combining with other drugs and/or alcohol • Accidental overdose • Physical dependence and withdrawal risks • Over-reliance on for “chemical coping”

18. Relative Risk Related to “Controlled Medications” DEA Scheduling of medications is related to perceived relative potential for abuse: Schedule 1: Heroin, LSD, MDMA Schedule 2: Methadone, oxycodone, amphetamines Schedule 3: Hydrocodone, buprenorphine Schedule 4: Benzodiazepines, Ambien, Provigil Schedule 5: Cough meds with codeine Schedule 6: Marijuana (NC)

19. Signs of Progression to Drug Abuse • Development of recurrent pattern of problems related to the use of the particular drug or drugs: Emotional/Physical Interpersonal/Social Occupational/Legal • Escalating use of the drug • Continued use of the drug in spite of these problems

20. Diagnosis of Dependence on Alcohol or Other Drugs Tolerance Withdrawal Loss of control over amount consumed Preoccupation with controlling use Preoccupation with related activities Impairment of social, occupational, orrecreational activities Use is continued despite persistent problems related to use Maladaptive pattern of use leading to clinicallysignificant impairment or distress, manifested within a 12-month period by at least 3 of the following: DSM-IV-TR. American Psychiatric Association: Washington, DC; 2000.

21. Compared with “Physical” Dependence Withdrawal syndrome when the drug is withdrawn acutely. May or may not be associated with increasing doses and increasing tolerance to the drug. May or may not be associated with abuse of the drug.

22. Opioid Withdrawal Anxiety/Restlessness Rhinorrhea Dilated pupils Nausea/Diarrhea Abdominal cramps Muscle spasms - jerking/restless legs: “kicking the habit” Piloerection - goose-bumps: “going cold turkey”

23. Case Discussions • What do issues of use vs abuse vs dependence mean in the setting of DTC (“But alcohol is legal isn’t it...”)? • How do these issues present in the setting of “recreational drug use” (“But that’s not my drug of choice...”)? • How do these issues present in relation to prescribed drugs with abuse potential (“But I’ve got a prescription for the Xanax...”)?