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MEDICATION SUPPORTED RECOVERY

MEDICATION SUPPORTED RECOVERY. Steven Kipnis MD, FACP, FASAM Medical Director, NYS OASAS. WHAT IS THE MOST COMMONLY USED PSYCHOACTIVE SUBSTANCE IN THE WORLD?. WHAT IS THE MOST COMMONLY USED PSYCHOACTIVE SUBSTANCE IN THE WORLD?. WHAT IS THE FIRST SPORT TO TEST FOR DRUGS?.

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MEDICATION SUPPORTED RECOVERY

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  1. MEDICATION SUPPORTED RECOVERY Steven Kipnis MD, FACP, FASAM Medical Director, NYS OASAS

  2. WHAT IS THE MOST COMMONLY USED PSYCHOACTIVE SUBSTANCE IN THE WORLD?

  3. WHAT IS THE MOST COMMONLY USED PSYCHOACTIVE SUBSTANCE IN THE WORLD?

  4. WHAT IS THE FIRST SPORT TO TEST FOR DRUGS?

  5. WHAT IS THE FIRST SPORT TO TEST FOR DRUGS?

  6. Mystery of Change • Why do people who seem to want to stop using alcohol and drugs continue to use? • Motivation • Ambivalence about initiating change • Changes in level of motivation • Environmental and social influences • Exposure to substances or reminders of using • Spending time with social group that continues to use • Psychosocial stressors • Everyday life problems (e.g., work, family, finances) • Major life problems (e.g., medical conditions, homelessness) • Psychological Disorders • Comorbid anxiety, depression, PTSD

  7. coping skills genetics co-dependency 12 step involvement social support family dynamics reward contingencies changes in brain chemistry prolonged withdrawal problem severity cognitive impairment Mystery of Change • What factors affect treatment and recovery efforts?

  8. A Complex Disorder Neurobiologicaldysregulation should be treated with pharmacotherapy Nutritional deficits should be treated with dietary improvements and supplementation Substance Dependence Dysfunctional behavior should be addressed with psychosocial interventions

  9. Changes in Brain Chemistry • Drugs of abuse produce their effects by altering brain chemistry and structure. • Neurotransmitters and associated receptors responsible for everyday functions are altered by the consumption of drugs.

  10. Rats give THC as adolescents • Rats exposed to heroin as adults • THC+ rats used heroin at a higher rate than THC – exposed rats • Same is true for nicotine • Protein changes on autopsy

  11. Adults Who Initiate Alcohol Use Before Age 21 More Likely to Abuse or Become Dependent on Alcohol • Early onset of alcohol use is associated with a greater likelihood of developing alcohol abuse or dependence at a later age, according to data from the National Survey on Drug Use and Health (NSDUH). • Those who first used alcohol at or before the age of 14 were nearly four times more likely to meet the criteria for past year alcohol abuse or dependence than those who started using alcohol between the ages of 18 and 20 (16.5% vs. 4.4%) and more than six times more likely than those who started using alcohol at or after age 21 (16.5% vs. 2.5%). • These findings illustrate the need for alcohol education and prevention efforts as early as middle school. Percentage of Adults (Ages 21 or Older) Who Abused or Were Dependent on Alcohol in the Past Year, by Age of First Alcohol Use, 2009 SOURCE: Adapted by CESAR from Substance Abuse and Mental Health Services Administration, Results from the 2009 National Survey on Drug Use and Health: Detailed Tables, 2010. Available online at http://oas.samhsa.gov/WebOnly.htm#NSDUHtabs.

  12. Early Marijuana Use Related to Later Illicit Drug Abuse and Dependence Percentage of Adults (Ages 18 or Older) Who Abused or Were Dependent on Illicit Drugs in the Past Year, by Age of First Marijuana Use, 2009 • Adults who first started using marijuana at or before the age of 14 are most likely to have abused or been dependent on illicit drugs in the past year, according to data from the National Survey on Drug Use and Health (NSDUH). Adults who first used marijuana at age 14 or younger were six times more likely to meet the criteria for past year illicit drug abuse or dependence than those who first used marijuana when they were 18 or older (12.6% vs. 2.1%)

  13. Dopamine and Reward • Dopamine is one of the primary neurotransmitters in the experience of pleasure and the maintenance of addiction. Many drugs of abuse stimulate neurons in the ventral tegmental area, releasing dopamine in the nucleus accumbens and prefrontal cortex. Nearly all drugs of abuse increase dopamine in the nucleus accumbens, which appears to be the primary reinforcement center of the brain. Image Credit: NIDA : “The Neurobiology of Drug Addiction”

  14. NAc VTA Amphetamine Cocaine Opioids Cannabinoids Phencyclidine Opioids Ethanol Barbiturates Benzodiazepines Nicotine HIPP GLU FCX AMYG CRF GLU 5HT GABA OPIOID OPIOID ENK GABA GABA VP DYN 5HT OFT DA BNST GABA NE LC ABN PAG NE HYPOTHAL END LAT-TEG To dorsal horn 5HT Raphé RETIC

  15. REWARD CIRCUIT

  16. Initial Pleasure

  17. Craving

  18. Generalizes to other Substances

  19. Binge Behavior

  20. Decreased Inhibitions

  21. Impaired Motor Control

  22. Loss of Control

  23. Family Problems

  24. Poor Performance at Work

  25. Neglecting Hygiene

  26. Major Loss of Focus

  27. Turn Loss of Focus into Financial Opportunity

  28. Regrets

  29. Medication Supported Recovery – Homer on a Diet - Eating a Rice Cake

  30. Natural Reward vs.Substance-Induced Reward • People seek out experiences that feel good. • These experiences are “natural reinforcers.” • Natural reinforcers stimulate release of dopamine. • Dopamine transmission: • Natural reinforcer • Dopamine transmission: • Substance-induced • Nearly all drugs of abuse also increase dopamine availability. • Dopamine release in the nucleus accumbens is 3-5 times greater for substances than natural reinforcers.

  31. Down-Regulation of Dopamine • Dopamine transmission: • Natural reinforcer • Dopamine transmission: • Substance-induced • Dopamine transmission: • Down-regulated • Continual activation of the dopamine pathway altersthe availability of dopamine. • The reduction or down-regulation in dopamine availability has a blunting effect on the natural reward circuit.

  32. IT IS NOT ABOUT THE BRAIN BEING ADDICTED TO A SUBSTANCE, IT’S ABOUT THE BRAIN BEING ADDICTED TO ITS OWN CHEMISTRY

  33. Neurotransmitters, Medications and the Receptor Site

  34. AGONIST

  35. PARTIAL AGONIST

  36. ANTAGONIST

  37. ADDICTION MEDICINES ACAMPROSATE ANTABUSE ANTICONVULSANTS BACLOFEN BUPRENORPHINE CLONIDINE METHADONE/LAAM NALTREXONE NALOXONE NEURONTIN NICOTINE REPLACEMENT THERAPIES SSRI’S ZYBAN VACCINES

  38. BARRIERS MEDICATION PATIENT PHYSICIAN/NURSE COUNSELOR PROGRAM SYSTEM

  39. BARRIERS MEDICATION INSUFFICIENT EVIDENCE REGARDING EFFICACY CONTRADICTORY EVIDENCE TOO EXPENSIVE NALTREXONE $2.50 - 4.43 PER DAY CORRECT DOSE? SIDE - EFFECTS

  40. BARRIERS MEDICATION CANDIDATE SELECTION TOOLS NEED TO BE RESEARCHED - WHO WILL BENEFIT MOST? POTENTIAL FOR ABUSE POTENTIAL FOR DIVERSION “MAGIC BULLET THEORY” DELIVERY SYSTEM

  41. BARRIERS PATIENT COMPLIANCE SELECTION STIGMA COST/INSURANCE COVERAGE

  42. BARRIERS PHYSICIAN/NURSE LACK OF AWARENESS LACK OF TRAINING LACK OF ONGOING TECHNICAL ASSISTANCE DO NOT PROMOTE USE MD’S NEEDED AT ALL PROGRAMS EXTRA WORK OBSERVATION TIME

  43. BARRIERS COUNSELOR LACK OF AWARENESS LACK OF TRAINING COUNSELORS IN RECOVERY “NOT THE WAY I DID IT” MORE WORK AFTERCARE

  44. BARRIERS PROGRAM NEED PHYSICIAN SERVICES NEED TO INCREASE COMMUNICATION BETWEEN PHYSICIANS AND COUNSELORS NEED LINKAGE TO MD AFTERCARE MONITOR DRUG LEVELS MONITOR SIDE - EFFECTS WRITE RX ENDANGERS PROGRAM INTEGRITY (THERAPEUTIC COMMUNITY)

  45. BARRIERS SYSTEM REGULATIONS NEED TO BE CHANGED WHO WILL PAY FOR MD SERVICES NEED INCREASE IN EDUCATION AND T.A. PRIVATE MD’S NEED TO BE ABLE TO LINK TO THE SYSTEM NEED OUTCOME DATA

  46. Antabuse®(disulfiram)1 ReVia®(naltrexone)2 Campral® (acamprosate)3 VIVITROL®(naltrexone for extended-release injectable suspension)4 30 tabs/month*(1 tab/day) 180 tabs/month*(2 tabs, 3x/day) 30 tabs/month*(1 tab/day) 1/month 1951 2004 2006 1994 Medications for Alcohol Dependence 1. Antabuse full Prescribing Information. Odyssey Pharmaceuticals, Inc. 2. ReVia full Prescribing Information. Duramed Pharmaceuticals, Inc. 3.Campral full Prescribing Information. Merck Santé s.a.s. 4.VIVITROLfull Prescribing Information. Alkermes, Inc.

  47. Current Pharmacotherapies 2 general categories: - anticraving (naltrexone, acamprosate) - alcohol-aversion (dilsufiram) Pharmacotherapies should be used in combination with psychosocial treatment.

  48. Opioid Receptors and Alcohol Dependence 1. Gianoulakis C. Alcohol Health Res World. 1998;22:202-210. 2. Woodward JJ. Principles of Addiction Medicine. 3rd ed. 2003:101-118.

  49. Naltrexone: Adverse Effects - generally well tolerated • minor side effects in 10% patients: nausea, dizziness and headache • Start with lower dose 12.5 – 25 mg and build up to 50mg

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