Impact and Treatment of Opioid Dependence

1. Impact and Treatment of Opioid Dependence Thomas E. Freese, PhD PI/Director, Pacific Southwest Addiction Technology Transfer Center Director of Training, UCLA Integrated Substance Abuse Programs Asst Research Psychologist, UCLA David Geffen School of Medicine

3. SPLENDID FOR Wind, Colic, Griping in the Bowels, Diarrhea Cholera and Teething Troubles

5. Prevalence of Opioid Use and Abuse in the United States

6. Rates of Current Heroin Use Drug demand data show that, nationally, current heroin use is stable or decreasing. (SAMHSA, 2009)

7. Who Uses Heroin? Individuals of all ages use heroin: More than 3.8 million US residents aged 12 and older have used heroin at least once in their lifetime. Heroin use among high school students is a particular problem. Slightly more than 2% percent of US high school seniors used heroin at least once during their lifetime. Approximately 1.6% of young adults (ages 19-28) reported lifetime use (CDC, 2009; SAMHSA, 2007)

8. Prevalence of Use • Rates ofheroin use are declining among youth - • 8th grade use peaked in 1996 • 10th grade use peaked in 1997 • 12th grade use peaked in 2000 • Rates ofnon-medical use of opioids are increasing • Rates in all ages peaked in 2007 • Rates highest in 18-25 year olds (Johnston et al., 2009; SAMHSA, OAS, NSDUH, 2009)

9. Initiation of Heroin Use During the latter half of the 1990s, the annual number of heroin initiates rose to a level not reached since the late 1970s. In 1974, there were an estimated 246,000 heroin initiates. Between 1988 and 1994, the annual number of new users ranged from 28,000 to 80,000. Between 1995 and 2001, the number of new heroin users was consistently greater than 100,000. Between 2002 and 2008, the number of new heroin users ranged from 91,000 to 114,000. (SAMHSA, 2008; 2009)

10. According to the 2007 National Survey on Drug Use and Health: An estimated 6.9 million persons (2.8% of the U.S. population aged 12 or older) were currently using certain prescription drugs nonmedically. An estimated 5.2 million were current users of pain relievers for nonmedical purposes. Approximately 4.4 million persons had used OxyContin nonmedically at least once in their lifetime. Non-medical pain reliever incidence increased from 1990 (628,000 initiates) to 2007, when there were 2.1 million new users. Other Opioid Use in a National Survey Population (SAMHSA, 2008; 2009a; 2009b)

11. According to the Drug Abuse Warning Network - 2004-2008: An estimated 200,666 drug misuse/abuse ED visits were related to heroin. One-third (33%) of nonmedical use ED visits were related to Central Nervous System (CNS) agents. Among CNS agents, the most frequent drugs were opiates/opioid analgesics, specifically: Hydrocodone/combinations (22,912 visits) Oxycodone/combinations (44,489 visits) Methadone (23,498 ED visits) Emergency Department Visits Related to Heroin/Other Opioids (SAMHSA, 2009)

12. New Non-Medical Users of Pain Relievers In 2008 – 2.2 million new non-medical users (a decline from 2.5 million in 2003, but still a lot!) 6,000 new users per day Among youth aged 12-17, females more likely to use non-medically Among young adults aged 18-25, males more likely to use non-medically (SAMHSA, OAS, 2009)

13. Treatment Admissions for Opioid Addiction

14. Heroin & Other Opioid Treatment Admissions TEDS admissions for primary opioid abuse increased from 16% of all admissions in 1997 to 19% in 2007. Admissions for other opioids have increased consistently since the late 1990s – 1% to 5% between 1997 and 2007. (SAMHSA 2009).

15. National Treatment Admissions for Heroin and Other Opiates in 2007 Percentage of Treatment Admissions by Age (SAMHSA, OAS, 2009)

16. Primary Heroin Treatment Admissions vs. Primary Other Opiate Treatment Admissions: A Side-by-Side Comparison (SAMHSA, OAS, 2009a; 2009b)

17. Substance Abuse Challenge:Prescription Drug Sources: Primarily Friends or Family Sources of Opioid Pain Relievers Used Non-Medically Source: SAMHSA, 2005 National Survey on Drug Use and Health, September 2006

19. Prescription Drug Abuse: What are we talking about?

20. Overview • Three classes of commonly abused Rx drugs (opioids, sedatives, stimulants) • What are they? • How do they act in the brain and body? • What are their effects? • Neurobiology

22. What are opioids? • Opiate: derivative of opium poppy • Morphine • Codeine • Opioid: any compound that binds to opiate receptors • Semisynthetic (including heroin) • Synthetic • Oral, transdermal and intravenous formulations • Narcotic: legal designation

23. Opioids

24. Opioids: Acute Effects • Euphoria • Pain relief • Suppresses cough reflex • Histamine release • Warm flushing of the skin • Dry mouth • Drowsiness and lethargy • Sense of well-being • Depression of the central nervous system (mental functioning clouded)

25. Long-Term Effects of Opioids • Fatal overdose • Collapsed veins • Infectious diseases • Higher risk of HIV/AIDS and hepatitis • Infection of the heart lining and valves • Pulmonary complications & pneumonia • Respiratory problems • Abscesses • Liver disease • Low birth weight and developmental delay • Spontaneous abortion • Cellulitis

26. Opioid Receptors • Receptor types • mu, delta, kappa • Receptors located throughout body • Pain relief: central and peripheral nervous system • Reward and reinforcement: deep brain structures • Side effects: constipation, sedation, itch, mental status changes

27. SOURCE: National Institute on Drug Abuse, www.nida.nih.gov.

28. Endogenous Opioids • Produced naturally in body • Act on opioid receptors • Examples: endorphins, enkephalins, dynorphins, endomorphins • Produce euphoria and pain relief; naturally increased when one feels pain or experiences pleasure

29. Opioid Withdrawal • Dysphoric mood • Nausea or vomiting • Diarrhea • Tearing or runny nose • Dilated pupils • Muscle aches • Goosebumps • Sweating • Yawning • Fever • Insomnia

30. Opiates and Reward Opiates bind to opiate receptors in the nucleus accumbens: increased dopamine release

31. Medication-Assisted Treatment Myths Myth #1: Medications are not a part of treatment. • The pharmacotherapies that are FDA-approved for treatment of addiction should be used in conjunction with psycho-social-educational-spiritual therapy. Therefore, medications can be used as a part of treatment, but only one part. • Medications are used in the treatment of many diseases, including addiction. • Making the final decision about whether or not medications are a part of a client’s treatment is out of the counselor’s scope of practice.

32. Medication-Assisted Treatment Myths Myth #2: Medications are drugs, and you cannot be clean if you are taking anything. • The field needs to change terminology to reflect current trends. “Drugs” are illicit psychoactive substances that are used to achieve a “high.” “Medications” are available by prescription and are used to treat an illness, disorder or disease. • Millions of Americans use medications (e.g., Zyban, nicotine patches) to quit smoking, and this practice is widely encouraged by addiction professionals. • Physical dependence and addiction are not the same thing. • The goal of addiction treatment is to assist a client in stopping his or her compulsive use of drugs or alcohol and love a normal, functional life.

33. Medication-Assisted Treatment Myths Myth #2: Medications are drugs, and you cannot be clean if you are taking anything. • If appropriately administered, medication-assisted treatment for addiction will not produce euphoric effects. • Pharmacotherapies are effective. Clinical data suggest that clients perform better in treatment when psycho-social-educational-spiritual therapy is combined with appropriate pharmacotherapies.

34. Medication-Assisted Treatment Myths Myth #3: Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) does not support the use of medications. • Neither Alcoholics Anonymous (AA)/Narcotics Anonymous (NA) literature nor its founding members spoke or wrote against using medications. • Even today, AA/NA does not endorse encouraging AA/NA participants to not use prescribed medications or to discontinue taking prescribed medications for the treatment of addiction.

35. TheBig Book states, “God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitated to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.” (Chapter 9, Emphasis added) Medication-Assisted Treatment Myths Myth #3: Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) does not support the use of medications.

36. Behavioral Interventions Without question, medication interventions have been extremely effective and beneficial to the patient in early, as well as long-term recovery. However, it is imperative that pharmacotherapies are paired with some form of evidence-based behavioral therapeutic intervention.

37. Behavioral Interventions Psychosocial therapy interventions that have been thoroughly researched and have shown good efficacy include: • Cognitive Behavioral Therapy (CBT) • Motivational Interviewing (MI) • Motivational Incentives/Contingency Management The Addiction Technology Transfer Centers (ATTC) have developed helpful resources for evidence-based practices: www.nattc.org/resPubs/bpat/index.html .

38. Medical Treatments for Opioid Addiction

39. death Full Agonist (e.g., methadone) Partial Agonist (e.g. buprenorphine) Antagonist (e.g. Naloxone) Partial vs. Full Opioid Agonist Opiate Effect Dose of Opiate

40. A Brief History of Medical Treatment for Opioids 1882 engraving of the British opium warehouse in Patna, India

41. A Brief History of Opioid Treatment • Neolithic era (9000 B.C.E. to 3000 B.C.E.) Opium cultivated for food, anesthesia, and ritual purposes • 15th Century: Recreational use of opium reported, but use was limited by its rarity and expense • 1874: Heroin was first synthesized

42. A Brief History of Opioid Treatment • 1964: Methadone is approved. • 1974: Narcotic Treatment Act limits methadone treatment to specifically licensed Opioid Treatment Programs (OTPs). • 1984: Naltrexone is approved, but has continued to be rarely used (approved in 1994 for alcohol addiction). • 1993: LAAM is approved (for non-pregnant patients only), but is underutilized.

43. A Brief History of Opioid Treatment, Continued • 2000: Drug Addiction Treatment Act of 2000 (DATA 2000) expands the clinical context of medication-assisted opioid treatment. • 2002: Tablet formulations of buprenorphine (Subutex®) and buprenorphine/naloxone (Suboxone®) were approved by the Food and Drug Administration (FDA). • 2004: Sale and distribution of ORLAAM® is discontinued.

44. Medications to Treat Addiction • Addiction is a chronic, relapsing brain disease characterized by compulsive use despite harmful consequences • Medications as part of comprehensivetreatment plan • Treatment approaches: • Medications (Bio) • Therapy, lifestyle changes (Psycho-Social) • Thorough evaluation and diagnosis essential

45. Pharmacotherapy in Substance Use Disorders • Treatment of withdrawal (“detox”) • Treatment of psychiatric symptoms or co-occurring disorders • Reduction of cravings and urges • Substitution therapy

46. Naltrexone General Facts • Generic Name: naltrexone hydrochloride • Marketed As: ReVia and Depade • Purpose: To discourage opioid use by reducing or eliminating the euphoric effects experienced by consuming exogenous administered opioids. • Indication: In the treatment of alcohol dependence and for the blockade of the effects of exogenous administered opioids. • Year of FDA-Approval: 1984

47. Naltrexone Administration Amount: one 50mg tablet Method: mouth Frequency: once a day Can be crushed, diluted or mixed with food. Abstinence requirements: must be taken at least 7-10 days after last consumption of opioids; abstinence from alcohol is not required;

48. Appropriate Populations Age Range: 18 to 65 years old Adolescents: Has not been tested or FDA-approved. Elderly: Has not been tested or FDA-approved. Pregnancy: Has not been adequately tested on pregnant or nursing women; Pregnancy Category C designation, used only if the potential benefit justifies the potential risk to the fetus. Polysubstance Abusers: Has not been adequately tested with this population.

49. How Does Naltrexone Work? Opioids enter the system and activate the areas of the brain known as the ventral tegmental area and the nucleus accumbens (the pleasure centers). In response to this increased endogenous opioid activity, dopamine is released. Since dopamine is a main reward neurotransmitter, increases in the nucleus accumbens makes the user feel good. The brain remembers those good feelings caused by the dopamine and opioids. The brain desires to repeat the behavior again to get the same good feelings.

50. How Does Naltrexone Work? • Naltrexone is an opioid receptor antagonist and blocks opioid receptors. N = naltrexone N N By blocking opioid receptors, the “reward” and acute reinforcing effects from dopamine are diminished, and alcohol consumption is reduced. N Post-Synaptic Neuron N Opioid Receptor N N