Disclosures I have nothing to disclose Updates on the care of - - PowerPoint PPT Presentation

3/12/2016 1

Updates on the care of people with addictions

Diana Coffa, MD Residency Program Director UCSF Family and Community Medicine

Disclosures

I have nothing to disclose

Objectives

Explore how definitions and language

around addiction impact stigma and treatment

Describe the SBIRT model Identify and discuss medications that

can be used in primary care to treat addiction

New issues in defining addiction

New DSM 5 criteria Language of substance use Popular perceptions of addiction

http://mp3tome.parseapp.com/article/news/2365302/addiction-facts-video-watch/

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DSM 5

Remove terms abuse and dependence Replace with spectrum of Substance

Use Disorder (SUD)

Craving added as a criterion Problems with law enforcement

removed

DSM 5 criteria for Substance Use Disorder

Recurrent use resulting in failure to fulfill major roles or

• bligations at work, home, or school

Recurrent use in hazardous situations Recurrent continued use despite social or interpersonal

problems caused or exacerbated by drugs

Tolerance Withdrawal Cravings A great deal of time getting or using the substance, or

recovering from use

Use of more than intended or for longer than intended Persistent desire or efforts to cut down Important activities given up or reduced due to

substance use

Continued use despite knowledge of physical or

psychological problems

2-3 Mild, 4-5 Moderate, >5 Severe

Roles Compulsion

Relationship

Craving Risk

Control

Consequence

Stigma in underserved populations

Addiction treatment is often

limited by

Shame Low sense of self-efficacy History of failure and fear of

recurrent failure

Moralistic undertones Stigma inducing Stigma mitigating Addict, Abuser, Junkie, Tweaker Abuse Clean, Dirty Habit Replacement or Substitution therapy User IVDU PSA

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Stigma inducing Stigma minimizing Addict, Abuser, Junkie, Tweaker Person with addiction Person in active addiction Person with substance use disorder Abuse Clean, Dirty Habit Replacement or Substitution therapy User IVDU PSA Stigma inducing Stigma minimizing Addict, Abuser, Junkie, Tweaker Person with addiction Person in active addiction Person with substance use disorder Abuse Use disorder Harmful use, risky use Clean, Dirty Habit Replacement or Substitution therapy User IVDU PSA Stigma inducing Stigma minimizing Addict, Abuser, Junkie, Tweaker Person with addiction Person in active addiction Person with substance use disorder Abuse Use disorder Harmful use, risky use Clean, Dirty Negative, positive, discordant Habit Replacement or Substitution therapy User IVDU PSA Stigma inducing Stigma minimizing Addict, Abuser, Junkie, Tweaker Person with addiction Person in active addiction Person with substance use disorder Abuse Use disorder Harmful use, risky use Clean, Dirty Negative, positive, discordant Habit Addiction, substance use disorder Replacement or Substitution therapy User IVDU PSA

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Stigma inducing Stigma minimizing Addict, Abuser, Junkie, Tweaker Person with addiction Person in active addiction Person with substance use disorder Abuse Use disorder Harmful use, risky use Clean, Dirty Negative, positive, discordant Habit Addiction, substance use disorder Replacement or Substitution therapy Treatment Medication assisted treatment User IVDU PSA Stigma inducing Stigma minimizing Addict, Abuser, Junkie, Tweaker Person with addiction Person in active addiction Person with substance use disorder Abuse Use disorder Harmful use, risky use Clean, Dirty Negative, positive, discordant Habit Addiction, substance use disorder Replacement or Substitution therapy Treatment Medication assisted treatment User Person who uses… IVDU PSA Stigma inducing Stigma minimizing Addict, Abuser, Junkie, Tweaker Person with addiction Person in active addiction Person with substance use disorder Abuse Use disorder Harmful use, risky use Clean, Dirty Negative, positive, discordant Habit Addiction, substance use disorder Replacement or Substitution therapy Treatment Medication assisted treatment User Person who uses… IVDU PWID (person who injects drugs) PSA Stigma inducing Stigma minimizing Addict, Abuser, Junkie, Tweaker Person with addiction Person in active addiction Person with substance use disorder Abuse Use disorder Harmful use, risky use Clean, Dirty Negative, positive, discordant Habit Addiction, substance use disorder Replacement or Substitution therapy Treatment Medication assisted treatment User Person who uses… IVDU PWID (person who injects drugs) PSA Person who uses…

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Is Addiction a Disease?

Two “No” arguments

• It is a voluntary, hedonistic choice
• It is a socially mediated, politically mediated,

culturally mediated, behaviorally mediated, environmentally mediated, complex phenomenon. It is not simply an organic brain disease.

Is Diabetes a Disease?

• Behaviorally mediated
• Environmentally mediated
• Socially mediated
• Politically mediated
• Culturally mediated
• Not just an organic pancreatic disease

Addiction is a complex disease

• Behaviorally mediated
• Socially mediated
• Politically mediated
• Environmentally mediated
• Culturally mediated
• Emotionally mediated
• Genetically mediated
• Pharmacologically mediated
• Organic brain disease

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Addiction as an organic brain disease

• Disrupted voluntary behavioral control
• Supraphysiologic dopamine release at nucleus

accumbens

Massive reward

Volkow N et al. Neurobiologic Advances from the Brain Disease Model of Addiction. N Engl J Med 2016; 374:363-371 Jan 28, 2016

Natural Reward Elevates Dopamine Levels

50 100 150 200 60 120 180

Time (min)

% of Basal DA Output Empty Box Feeding

Source: Di Chiara et al.

100 150 200 DA Concentration (% Baseline)

Mounts Intromissions Ejaculations Source: Fiorino and Phillips

SEX FOOD

100 200 300 400 500 600 700 800 900 1000 1100 1 2 3 4 5 hr Time After Amphetamine % of Basal Release DA DOPAC HVA Accumbens AMPHETAMINE 100 200 300 400 1 2 3 4 5 hr Time After Cocaine % of Basal Release DA DOPAC HVA Accumbens

COCAINE

100 150 200 250 1 2 3 4 5hr Time After Morphine % of Basal Release Accumbens 0.5 1.0 2.5 10

Dose (mg/kg)

MORPHINE

100 150 200 250 1 2 3 hr Time After Nicotine % of Basal Release Accumbens Caudate

NICOTINE

Source: Di Chiara and Imperato

Effects of drugs on dopamine release

Addiction as an organic brain disease

• Disrupted voluntary behavioral control
• Supraphysiologic Dopamine release at nucleus

accumbens

Massive reward Increased salience

• Over time, diminished intrinsic dopamine release in

limbic system

Baseline dysphoric state with decreased reward and

salience from natural reward stimuli

• Diminished dopamine and glutamate release in

frontal cortex

Decreased executive function, impulse control

Volkow N et al. Neurobiologic Advances from the Brain Disease Model of Addiction. N Engl J Med 2016; 374:363-371 Jan 28, 2016

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Is it harmful to call addiction a disease?

• People with addiction sometimes describe the

disease label as demoralizing or diminishing.

“It makes it seem like a bigger deal than it is. It’s

just a habit that I need to quit. It’s not like there’s something wrong with me.”

• Concern that it implies a permanent change that

cannot be cured

Why is it useful to call addiction a disease?

Reduces stigma Reduces blame and increases

appropriate response to relapse

Leads to the most effective treatments:

medication assisted treatments

A compromise position

Treat addiction like a disease

Even if you don’t think it is one

• -Anna Lembke, MD

SBIRT Model of Care

Screening Brief Intervention Referral to Treatment

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Screening

USPSTF Grade B recommendation: Annual

Alcohol Screening and Brief Intervention for all adults

Same as mammograms

Risky Use

Low Risk Use Abstinence

SUD

Single Question Screener

How many times in the last year have

you had 4 or more (5 for men) drinks in

• ne day?

82% sensitive, 79% specific

Risky Use

Low Risk Use Abstinence

SUD

Smith et.al.

• J. GIM 2009

Single Question Drug Screener

How many times in the past year have

you used an illegal drug or used a prescription medication for non-medical reasons?

100% sensitive, 73.5% specific for drug use

disorder

Risky Use

Low Risk Use Abstinence

SUD

Smith et.al. Arch Int Med. 2009

If single question screen is positive

Further assess quantity, consequences,

and control

Provide Brief Intervention appropriate to

the level of use. Risky Use

Low Risk Use Abstinence

SUD

Screening Brief Intervention Referral to Treatment

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Referral to Treatment

Residential Treatment Outpatient Treatment

High intensity Moderate intensity Low intensity

Fellowship meetings Medication assisted therapy

Office Based Medication Assisted Therapy

Opioid Use Disorders Alcohol Use Disorders

Medication Assisted Treatment for Opioids

Methadone

Reduces

Death HIV Infections Heroin and other opioid use Criminal behavior

Cannot be prescribed for SUD in the

primary care setting

Mattick R et al. Cochrane Review 2009

Medication Assisted Treatment for Opioids

Buprenorphine

Lower retention than methadone Fewer barriers to treatment Fewer side effects Lower mortality rates Only MD’s can currently prescribe

Advocacy to expand to NP

Limited to 100 patients per MD

Likely raise cap soon

Ling et al. Drug and Alc Dep 2003

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Updates on Buprenorphine

Off label use of SL buprenorphine for

chronic pain

May be a good first line opioid for high

risk patients

Dose TID Transdermal form is FDA approved for

chronic pain

SL form only approved for OUD

Daitch et al. Pain Physician 2012 Malinoff et al.. Am J Ther. 2005

Updates on Buprenorphine

Increasing interest in home inductions

Dominant model for induction in Europe

Naltrexone

Oral Naltrexone

Effective in unusually externally

motivated patients

Injectable Naltrexone

May be more effective Low retention rate High risk of overdose

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Alcohol use disorder

Withdrawal management

Benzodiazepines Gabapentin

Myrick et al. Alcohol Clin Exp Res. 2009

Alcohol use disorder

Maintenance

Naltrexone 25mg->150mg/d

Return to any EtOH: 5-40%

reduction, NNT 201

Return to heavy drinking: 20-35%

reduction1

Can be used PRN before planned

drinking events 2

Injectable depo form less well studied

but may increase retention in treatment3

1 AHRQ Comparative Effectiveness Review #134 201 2 Kranzler J Clin Psychopharmacol 2003 3 O’Malley J Clin Psychoparmacol 2007

Alcohol use disorder

Clinical use of naltrexone

Can cause hepatotoxicity Avoid if transaminases >5x ULN Ideally 3-7 days of abstinence

before initiation

SE: nausea, rare headache,

dizziness

Cannot take opioid agonists Non-responders

Alcohol use disorder

Acamprosate 666mg TID

Consistently effective in European trials1 No effect in two large US studies2, 3 Similar side effect profile to naltrexone Avoid in severe liver disease or severe renal

disease

Disulfiram 250mg-500mg/d

Low retention, poor studies Monitor LFTs, neuropathy and vision

changes

1 Kranzler Am J Addict 2008 2 Anton JAMA 2006 3 O’Malley Arch Int Med 3003

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Alcohol use disorder

Gabapentin 1800mg daily

Additive with naltrexone

Topiramate 25mg 300mg

Mason B et al. JAMA Int Med 2014

Johnson Lancet 2003

Summary

The words we use matter We should treat addiction like a disease

That may be curable And is definitely treatable

Screen everyone

Provide brief interventions to people with

risky use and SUDs

Provide referral to treatment for all SUD

You can prescribe medications to treat

• pioid or alcohol use disorders