Addiction Update: Emerging Trends and Medication Options

1. Addiction Update: Emerging Trends and Medication Options Ernest rasyidi, m.d.

2. Alcohol Use in the U.S. Estimated 133.4 million current drinkers in 2011 About 58.3 million people Binge Drank in past 30 days About 15.9 million people were heavy drinkers About 9.7 million persons aged 12 to 20 (25.1 percent of this age group) reported drinking alcohol in the past month Among the under aged, about 6.1 million were binge drinkers, and 1.7 million were heavy drinkers

3. Alcohol Use Rates

4. Alcohol Use: Definitions Current (past month) use - At least one drink in the past 30 days. Binge use - Five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days. Heavy use - Five or more drinks on the same occasion on each of 5 or more days in the past 30 day

5. Alcohol Use Ages 12-20

6. Alcohol

7. Alcohol Cont… A “forty” = 40 oz beer ~ 3+ drinks, malt liquor stronger, “40” ~ 4.5 drinks “Tall boy” = 24 oz = 2 drinks Standard wine bottle = 750mL = 5 drinks Pint of liquor = 11 drinks A “fifth” = 750mL = 17 drinks A “Handle” = 1.75L = 39 drinks This assumes 80 proof (40% alcohol) liquor, some are stronger

8. Naltrexone (Revia, Vivitrol): Alcohol Opiate receptor blocker Shown to reduce cravings Decreases frequency of use Decreases intensity of usage Main side effects: nausea, dysphoria, headache, fatigue

9. Naltrexone: Alcohol • Available Forms: • Daily pill • Monthly injection • Implant (coming soon?): Placed under the skin and replaced quarterly. Used in Australia off label, not approved in US

10. Disulfiram (Antabuse) Blocks acetylaldehyde dehydrogenase, and enzyme necessary to break down alcohol Causes acetylaldehyde to build up leading to “Disulfiram Reaction” Flushing, Nausea, Vomit, Headache, Racing Heart Beat, Dizziness Taken orally, at least daily to be effective Rare cases of lethal reaction when taken with alcohol (due to irregular heartbeat)

11. Gabapentin (Neurontin) Off label – Non FDA approved Anti-seizure medication Non-addictive Helps with anxiety related to Alcohol Withdrawal Wide dosing range (100mg-3600mg/day) Main side effects include drowsiness and dizziness

12. Topiramate (Topamax) Off label – Non FDA approved Anti-seizure medication Non-addictive Helps with impulsivity often seen in binge drinking Patients describe feeling like things are slowed down so they can think things through Main side effects: Cognitive slowing (“Dopamax”) and weight loss

13. Tobacco Use: 68.2 Million Users

14. Smoking Cessation Options Nicotine replacement: Patch, Lozenge, Gum, Inhaler Bupropion Varenicline: Beware vivid dreams and rare SI E-cigs?

15. Electronic Cigarrettes

16. Electronic Cigarette Structure

17. Rates of Drug Use: Ages 12 and Older NSDUH 2011

18. Rates of Drug Use 8.9% of Americans age 12 or older are “current” (used in the past month) users of any illicit drug 22.0% of full time college students age 18-22 are current users, comparable to their age matched peers (23.5%)

19. Cannabis Most widely used illicit drug Can be smoked, eaten, or in some rare cases liquid form Varies widely in cost and potency, but in general, most cannabis available currently is far more potent than cannabis consumed in 1960-70’s (4-5% THC vs 12-18% THC)

20. Cannabis 101 Infinite number of nicknames based on region and strain of plant being referred to. Most common generic terms include “weed” and “pot” Most strains are variations of Cannabis Indica, Cannabis Sativa, or some hybrid Indica ~ “body high” relaxing, sedating Sativa ~ “head high” psychedelic, mind altering THC = main psychotropically active ingredient, most concentrated in plant resin

21. Whole Plant

22. Cannabis Bud

23. THC concentrated resin

24. Cannabis Smoked Joints – Cannabis cigarettes Blunts – Hollowed out cheap cigars filled with Cannabis and re-wrapped Bowls – Cannabis packed into the bowl of a pipe Bong – Pipe with water filter element Vaporizer – Heats Cannabis so that THC evaporates and can be inhaled without burning plant material

25. Joints vs Blunts

26. Paraphernalia

27. Edibles

28. Units of Measurement “Dime bag” = $10 worth “Dub” = $20 worth A gram “eighth” = 1/8 oz = 3.5 grams = $40-60 for fairly high potency

29. An Eighth

30. Wax AKA Butane Hash Oil (BHO) Highly concentrated resin produced using a solvent, such as butane Production process can be dangerous as solvent are highly volatile, can lead to fires/explosions Sometimes can be mistaken for meth lab explosion

31. Wax

32. Rx Meds Benzos, downers, anxiety meds, sleep meds: Klonopin, Xanax, Valium, Ativan, Ambien Stimulants: Ritalin, Adderall Muscle Relaxers: Soma Rx opiates: Vicodin, Percocet (Percs), Oxycodone/contin (Oxy), Roxicodone (Roxy), morphine, dilaudid, methadone Rx opiates far more common than heroin Ask about crushing/snorting

33. Opiates: Naltrexone Blocks the “High” from opiates Reduces cravings Can precipitate withdrawals if Patient has opiates in their system

34. Opiates: Methadone Pure opiate Long acting, decreases cravings, should block the high from other opiates Can overdose Technically, should be administered in a highly structured setting (methadone clinic) with strict requirements. Fairly demanding but does provide structure and accountability

35. Opiates: Buprenorphine (Suboxone) Partial opiate agonist, binds very tightly, long acting Theoretically, should give enough activation to prevent cravings, not enough to get high. Because it binds so tightly to receptors, will prevent other opiates from having effect Will cause withdrawal if Patient has opiates in their body Warn patients about emergency procedures

36. Opiates: Buprenorphine (Suboxone) • Availability… • Tab (getting phased out) • Gel film • Implant good for 6 months (in testing)

37. Reformulated Tablets Resistant to Crushing Multiple strikes with a hammer deforms but does not crush reformulated tablets into powder From the Presentation To Joint Meeting of the Anesthetic and Life Support Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee, May 5 2008

38. Crushing Between Spoons Reformulation (left) cannot be crushed between spoons Original formulation (right) can be crushed between spoons From the Presentation To Joint Meeting of the Anesthetic and Life Support Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee, May 5 2008

39. Manual Crushing Followed by Dissolution From the Presentation To Joint Meeting of the Anesthetic and Life Support Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee, May 5 2008

40. Tampering for IV Abuse New formulation results in gelatinous material which cannot be drawn into a syringe for injection (the syringe is empty) From the Presentation To Joint Meeting of the Anesthetic and Life Support Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee, May 5 2008

41. Vignette #1 PAR

42. Vignette #2 PAR

43. CURES: Implications for Treatment PAR is not a substitute for drug testing, collateral info, or clinical judgment PAR should not be used to catch patients in a “gotcha” scenario. Patients with addiction often have severe guilt and shame associated with their use and treatment interventions should work to break these barriers down instead of re-enforcing them

44. CURES: Implications for Treatment PAR should be discussed at outset and is an important part of the structure/frame of treatment and results should be discussed PAR should promote safety by helping to reduce risk of overdose and drug interactions PAR should be used to help determine clinical decisions regarding level of care, frequency of monitoring, as well as risk/benefit of particular interventions

45. CURES Limitations • Be aware of possible false negatives! • Pharmacy participation is supposed to be mandatory and prescriptions should be reported within a week of dispensing. Even so, be aware that not all Rx’s will show up • Keep in mind that Veterans’ Administration Rx’s do not show up • Out of state Rx’s will not show up • No entries will show up if patient is using aliases or if they are diverting from friends/street

46. Heroin Balloons

47. Cocaine and Crack

48. Crystal Meth

49. Stimulants • No FDA approved treatments (all off-label use) • Bupropion (Wellbutrin): Antidepressant, works on similar chemicals to cocaine/amphetamine but in a different way • Concerta: Long acting form of Ritalin, currently undergoing trial, results look promising but raises concerns for abuse similar to opiate replacement therapy • Vaccines: In development for decades. Patients given an injection which stimulate immune response in body. Prevents cocaine from entering the brain, eliminates High. Does not protect from Overdose. Needs “booster” shots every few months. Raises legal/ethical concerns. (Parents wanting for kids “preventatively,” involuntary treatment, etc…)

50. Hallucinogenics LSD: paper tabs, ingested, rarely gelatin film. Difficult to obtain true LSD since 2000 Ecstasy, XTC, MDMA: tabs, often impure, typically mixed with amphetamines Hallucinogenic Mushrooms, ‘Shrooms, Psilocybin Peyote/Mescaline: Legitimate access restricted to certain Native American tribes, difficult to obtain Ayahuasca: Amazon jungle, holy sacrament for indigenous church