ADDICTION Michael Baron, MD, MPH, FASAM Medical Director Tennessee - - PDF document

▶
addiction
SMART_READER_LITE
LIVE PREVIEW

ADDICTION Michael Baron, MD, MPH, FASAM Medical Director Tennessee - - PDF document

Feb 09, 2024 247 likes •388 views

4/10/2018 ADDICTION Michael Baron, MD, MPH, FASAM Medical Director Tennessee Medical Foundation - Physicians Health Program DISCLOSURE I have no financial relationships to disclose. I will not discuss off label or investigational

slide-1
SLIDE 1

4/10/2018 1

Michael Baron, MD, MPH, FASAM Medical Director Tennessee Medical Foundation - Physician’s Health Program

ADDICTION

DISCLOSURE

I have no financial relationships to disclose. I will not discuss off label or investigational medication use in my presentation.

Board Certified - Anesthesiology, Psychiatry and Addiction Medicine 2010 – 1/2017 Board of Medical Examiners 2014 – 1/2017 Chair - CSMD Committee 2/2017 – present Medical Director – TMF- Physician’s Health Program Steering Committee: Chronic Pain Guidelines, DOH

OBJECTIVES

Attendees will

  • Learn the definitions of Addiction.
  • Understand the etiologies of Addiction.
  • Grasp the concepts and potencies of

non‐opioid analgesics.

  • Recognize Misprescribing and Drug

Seeking Behavior.

slide-2
SLIDE 2

4/10/2018 2

International Narcotic Control Board

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

5% 99% 53% 61% 37% 49%

2017 - % of World’s…

USA’s Appetite for Opioids

WHAT IS ADDICTION?

ORIGINAL RESEARCH

“Significant Pain Reduction in Chronic Pain Patients after Detoxification from High Dose Opiates”

Journal of Opioid Management 2:5 September/ October 2006 Michael Baron, MD

slide-3
SLIDE 3

4/10/2018 3

Individual Pain reports

Pre Post 1 2 3 4 5 6 7 8 9 10 Detox State Pain Self Report

Figure 1. Journal of Opioid Management , S ept ember/ Oct ober, 2006.

Change in Patient pain after detox

Pre post 1 2 3 4 5 6 7 8 9

*

P a in S e lf R e p

  • rt

Figure 2. Journal of Opioid Management , S ept ember/ Oct ober, 2006. Figure 3.

Pre Post Pre bup Post bup 1 2 3 4 5 6 7 8 9 Ibuprofen alone with buprenorphine

* *

P a in S e lf R e p

  • rts

Journal of Opioid Management , S ept ember/ Oct ober, 2006.

slide-4
SLIDE 4

4/10/2018 4

Number Needed for 50% Pain Relief

4.6 2.7 2.7 1.6 CATEGORY 1 Oxy 15mg Oxy 10 + APAP 650 Naproxen 500 Ibu 200 + APAP 500mg

Derry, C., Derry, S., & Moore, R. (2013).

Efficacy of Pain Medication

10 20 30 40 50 60 70 Ibuprofen 200 mg Acetaminophen 500 mg Ibuprofen 400 mg Oxycodone 15 mg Oxy 10 + acet 1000 Ibu 200 + acet 500

  • Bandolier. (2007). The Oxford

League Table of Analgesic Efficacy

  • JAMA. CHANG, 2017;318(17):1661-1667.

Efficacy of Pain Medication

slide-5
SLIDE 5

4/10/2018 5

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain.

240 randomized patients – 12 months Pain was significantly better in the nonopioid group. Adverse medication-related symptoms were significantly more common in the opioid group. Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.

  • JAMA. 2018:319(9):872-882

What is Addiction

Addiction is a brain disease

slide-6
SLIDE 6

4/10/2018 6

A primary, chronic disease of brain reward, motivation, memory and related circuitry

ADDICTION

WHAT IS ADDICTION?

Addiction is a Disease! Addiction is the single most preventable cause of Disability and Death in the US.

slide-7
SLIDE 7

4/10/2018 7

Addiction = Substance Use Disorder

NIDA ASAM

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired Control over drug use, Compulsive use, Continued use despite harm, and Craving. 4Cs‐

Substance Use Disorder = Addiction

DSM‐IV Abuse and Dependence

Abuse = Willful misuse Dependence = Addiction

DSM‐5 Substance Use Disorder

Recurrent use of alcohol or other drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. Depending on the level of severity, this disorder is classified as mild, moderate, or severe.

Biology/Genes Environment

DRUG

ADDICTION

Brain Mechanisms

Nora D. Volkow, M.D. National Institute on Drug Abuse

ADDICTION ADDICTION

slide-8
SLIDE 8

4/10/2018 8

ETIOLOGY - GENETICS

Children of Alcoholics:

  • Four times more likely to develop alcohol

problems then the general population.

  • Studies of Adopted‐away children of

persons with alcohol dependence

  • Higher risk for many other behavioral and

emotional problems.

ETIOLOGY - GENETICS

  • Genetic and environmental influences

may be correlated to substance initiation and use.

  • Progression to Addiction (Substance

Use Disorder) is more related to genetic factors.

ETIOLOGY - TRAITS

  • High novelty and sensation seeking
  • Impulsivity
  • Low harm avoidance
  • High reward dependence
  • Temperament – anxiety, aggression
  • r irritability
  • Intelligence – cognitive abilities
slide-9
SLIDE 9

4/10/2018 9

ETIOLOGY - ACE

Adverse Childhood Experiences The quantity of traumatic events experienced in childhood correlates with the development of addiction. The greater the number the more likely.

HIGH NUMBER OF ACE’s

Increasing Adverse Childhood Experiences strongly correlates with the risk for:

  • Substance use disorder/addiction
  • Anxiety disorders
  • Depression
  • Diabetes
  • Heart disease
  • Obesity
  • Suicide attempts
  • Increased risk for intimate partner violence
slide-10
SLIDE 10

4/10/2018 10

Etiology - Exposure

Length of postoperative opioid exposure associated with large increase in misuse.

  • Duration of opioid use was strongest predictor of

misuse.

  • 568,612 patients received postoperative opioids
  • Each refill and additional week of opioid use

associated with an adjusted increase in rate of misuse of 44%

BMJ 2018;360:j5790

NIDA

Which is the Cocaine Brain?

WHICH BRAIN IS ON DRUGS?

NIDA

NORMAL COCAINE

A BRAIN ON DRUGS

slide-11
SLIDE 11

4/10/2018 11

Brain Healing Takes Time

OPIOID DEATHS BY FENTANYL ANALOGS

MMWR Vol 66, October 27, 2017

3‐methylfentanyl, acrylfentanyl, butyrylfentanyl, para‐fluorofentanyl, para‐fluorobutyrylfentanyl, and para‐fluoroisobutyrylfentanyl

slide-12
SLIDE 12

4/10/2018 12

MISPRESCRIBING

Prescribing in quantities or frequency inappropriate for the complaint or illness. Examples:

  • Large quantities/frequent intervals/crescendo

pattern

  • Progression to multiple drugs
  • For trivial complaints
  • Family members
  • Known alcoholic or drug addict

Categories of Misprescribing

Dated: Fails to keep current Duped: Doesn’t detect deception Dysfunctional: Can’t say no Dismayed: Prescription is to make up for lack of time Dishonest: Prescribing for financial gain Disabled: Impaired judgment Disempowered: Skewed perception

  • f power

Disorganized: No systems in place Disregard for Scope: Practicing out

  • f specialty

Dodging: Using refills to avoid patient visits.

Suspect Drug‐Seeking Behavior in the Patient who . . .

slide-13
SLIDE 13

4/10/2018 13

  • A dramatic, compelling but vague complaint
  • Pressures for an increases in dose
  • Drug screens are negative for Rx’ed

medicine

  • Symptoms contradict clinical observation
  • Patient asks for a specific drug
  • Patient has no interest in the diagnosis
  • Rejects all treatment that is not opioids

Possible Drug-Seeking Behavior

  • Reports an NSAID Allergy
  • Has abundant pharmacologic knowledge
  • Patient makes veiled threats
  • Patient is very flattering
  • Primary doctor is out of town
  • Travels long distances to get to you
  • Primary doctor just retired

Possible Drug-Seeking Behavior THANK YOU