Neurobiology of Opioid Addiction & Physical Health Impacts - - PowerPoint PPT Presentation

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Neurobiology of Opioid Addiction & Physical Health Impacts

Thomas Kosten, M.D. Baylor College of Medicine

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Faculty Disclosure

• Dr. Kosten—Speakers Bureau: Cephalon,

Forest, Reckitt Benckiser; Consultant: Novartis, Bristol-Myers Squibb, Celtic, Alkermes, Synosia, Catalyst, Lannacher, Gerson Lerman Consultants

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Addiction

• Chemical dependency is a compulsive,

pathological, impaired control over drug use, leading to an inability to stop using drugs in spite of adverse consequences

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Essential Definitions

• Physical Dependence: Pharmacologic effect

characteristic of opioids; withdrawal or abstinence syndrome manifest on abrupt cessation of medication

• Tolerance: Pharmacologic effect characteristic
• f opioids; need to increase dose to achieve

the same effect or diminished effect from the same dose

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Essential Definitions

• Pseudo-Addiction: Pattern of drug-seeking

behavior of pain patients receiving inadequate pain management that can be mistaken for addiction; resolves with re-establishing analgesia

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Neurotransmitters

• Dopamine
• Opioid
• Glutamate
• GABA
• Cannabinoid
• Norepinephrine

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Drug Abuse

Acute Effects

• Positive Effects
• Reward
• Reinforcement

Chronic Effects

• Tolerance
• Dependence
• Sensitization

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Drug Abuse

• Addiction
• Detoxification-Withdrawal
• Craving
• Relapse

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Current Theory: Reward Pathway

• There is reward pathway in the brain which is

activated by

– Food, water and sex – Nurturing and caring for others – “Thrills” – Exercise

• This reward pathway is also activated by

– Drugs, including alcohol – Gambling

• Project Cork

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Neural Circuitry of Reward

• Present in all animals
• Produces pleasure for

behaviors needed for survival:

• eating
• drinking
• sex
• Nurturing

Project Cork

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All drugs of abuse bind to the neural circuitry of reward

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1-2 Min 3-4 5-6 6-7 7-8 8-9 9-10 10-20 20-30

Your Brain on Drugs

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Normal Cocaine Abuser (10 da) Cocaine Abuser (100 da)

Your Brain After Drugs

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All drugs of abuse increase dopamine in the nucleus accumbens

• alcohol
• cocaine
• heroin
• marijuana
• nicotine
• amphetamines
• sedatives
• hallucinogens
• pcp

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Definition

• “Addiction is a cycle of spiraling dysregulation
• f brain reward systems that progressively

increases, resulting in compulsive drug use and a loss of control over drug taking” George Koob

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Compulsion to use

The brain is altered by abuse of a psychoactive chemical and use becomes the only way to experience feeling good

• r normal

– No one ever starts drinking or using a drug intending to become an alcoholic or drug addicted – The focus of life is on obtaining access to, using, and recovering from a chemical that makes you high….OR IN THE END TO AVOID WITHDRAWAL OR FEEL NORMAL – Everything—social time, job performance, recreational

• pportunities—are given up or reduced because of this

focus

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Medical History Associated with Substance Abuse

• Medical history findings associated with

substance abuse: hepatitis C, HIV, TB, cellulitis, sexually transmitted diseases, elevated liver function tests

• Social history: motor vehicle accidents, DUIs,

domestic violence, legal history, loss of property in fire

• Psychiatric history

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Clinical Assessment: Psychosocial History

• Current psychiatric symptoms
• History of addictive disease
• Change in social function

– work – family and relationships – recreation

• Medical-legal status

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Pain and Addiction

• Nearly 1/3 of the US population has used illicit

drugs and an estimated 6-15% have a substance abuse disorder of some type

• An individual with chronic pain AND untreated

addictive disease WILL NOT get better with an

• pioid prescription

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Pain History

• Provocative or Palliative Features
• Quality
• Radiation
• Severity
• Timing

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Predictors of Opioid Misuse

• Behavior that Suggests Addiction

– Multiple episodes of prescription “loss” – Repeatedly seeking prescriptions from other clinicians or from the emergency rooms without informing prescriber,

• r after warnings to desist

– Evidence of deterioration in the ability to function at work, in the family , or socially, which appears to be related to drug use – Repeated resistance to changes in therapy despite clear evidence of adverse physical or psychological effects from the drug – Positive urine drug screen-other substance abuse

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Predictors of Opioid Misuse

• Dangerous Behavior

– Motor vehicle crash/arrest related to opioid or illicit drug or alcohol intoxication effects – Intentional overdose or suicide attempt – Aggressive/threatening/belligerent behavior in the clinic

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Define Your Role in Medication Prescribing

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Patient Medication Agreement

• A patient medication agreement establishes

clear expectations between physician and patient and specifies

– purpose of opioid therapy – side effects – treatment goals – physician’s role in responsible opioid prescribing – patient’s role in responsible opioid use

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Opioid Agreement

• Opioid prescriptions are provided by only one

Provider

• Patients agree not to ask for opioid medications from

any other doctor without the knowledge and assent

• f the provider
• Patients agree to keep all scheduled medical

appointments

• Urine drug screens will be obtained as indicated

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Opioid Agreement

• Patients agree to comply fully with all aspects of the

treatment program including behavioral medicine and physical therapy if recommended

• A prohibition on use with alcohol, other sedating

medications or illegal medications

• Agreement not to drive or operate heavy machinery

until medication-related drowsiness is cleared

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Adjuncts and Alternatives to Opioid Therapy

• Antidepressants
• NSAIDS
• Anticonvulsants
• Acetaminophen
• Muscle Relaxers
• Tramadol
• Medications for sleep
• Topical Agents
• Heat
• Prosthetic supports
• Physical therapy
• Exercise
• Cognitive-behavioral

therapy

• Interventional Pain

Management

• TENS Unit
• Orthopedic Consultation

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Exercise is important for everyone

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Don’t Forget to Look at Lifestyle

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Don’t forget about lifestyle changes

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Monitoring – Opioid Treatment Guidelines

• Clinicians should reassess patients on COT

periodically as warranted by changing

• circumstances. Monitoring should include

documentation of pain intensity and level of functioning, assessment of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies.

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Urine Drug Screen

• Urine drug screens typically check for

evidence of opiate, alcohol, benzodiazepine, cocaine, marijuana, amphetamine and barbiturate use

• Some opiates may need to be specifically

requested such as oxycodone, fentanyl, and methadone

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Length of Time Drugs of Abuse Can Be Detected in Urine

• Alcohol

7-12 hours

• Amphetamine 48 hours
• Barbiturate

24 hours to 3 weeks

• Benzodiazepines 3 days to 1 month
• Cocaine

3 days

• Marijuana

3 days to over 1 month

• Opioids

48 hours to 4 days

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Urine Drug Screens

Parameter Diluted Adulterated Creatinine Less than 20 ph Less than 3 Greater than 11 s.g. Less than 1.003 nitrite Greater than 500

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Substances that can be detected with u/a, color check and temperature

• Bleach
• Table salt
• Laundry detergent
• Toilet bowl cleaner

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Aberrant Behavior that Requires Attention

• Aggressive complaining about needing more of the

drug

• Drug hoarding during periods of reduced symptoms
• Requesting specific drugs
• Openly acquiring similar drugs from other medical

sources

• Unsanctioned dose escalation or other

noncompliance with therapy on one or two

• ccasions

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Aberrant Behavior that Requires Attention

• Unapproved use of the drug to treat other symptoms
• Reporting psychic effects not intended by the

clinician

• Resistance to a change in therapy associated with

adverse effects

• Missing appointments
• Not following other components of the treatment

plan (physical therapy, exercise, etc)

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Rationale for a primary care based chronic pain program Patients who do not follow-up with pain consultation are at high risk for substance abuse diversion psychiatric illness They frequently come back to the primary care provider demanding opiate therapy for their chronic pain

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Problems with high risk patients in a typical primary care visit

• Time constraints attempting to provide

primary care, adequate pain control, pain education

• Disruptive behavior related to patient

attempts to get inappropriate opiate prescriptions

• Increased stress on the primary care providers

which further limits their ability to care for

• ther patients in the clinic

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Pitfalls that need to be (are being) addressed

• The need for a more comprehensive and possibly

supervised drug screen for patients at the highest risk for problems

• The need for greater non-narcotic formulary options

for pain and/or mechanisms set up for greater dialogue between pharmacy and primary care when attempting non-formulary requests for opioid sparing medications, including antidepressants

• The need for treatment options for patients with

Substance abuse with a high degree of denial about their problem and/or who are in need of inpatient services

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Opioid Related Adverse Effects-Opioid Guidelines

• Clinicians should anticipate, identify, and treat

common opioid-associated adverse effects.

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Opioid Adverse Effects: Therapeutic Complications

• Hyperalgesia
• Hypogonadism
• Sedation
• Cognitive Impairment
• Constipation
• Nausea/Vomiting
• Pruritis
• Respiratory Depression
• Central Sleep Apnea

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Effects of Opioid Treatment

• Long-term opioid treatment is associated with

the development of tolerance to its analgesic effects

• Evidence is accumulating that opioid

treatment may also paradoxically induce abnormal pain sensitivity, including hyperalgesia and allodynia. Thus, increasing

• pioid doses may not improve pain control

and function

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Is Drug Addiction Treatment Worth The Cost?

• Drug addiction treatment is cost-effective in reducing

drug use and its associated health and social costs.

– Each dollar invested in treatment yields between $4-7 in reduced crime, court, and theft costs. – If health care savings are included as well, each dollar invested in treatment saves up to $12. (Chevron Study) – Medical insurance premiums cost for unlimited treatment increases costs by only 2 cents per day. (Rand Study)

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Addiction Treatment Works

• If you apply the same principles to the disease
• f addiction that you would use to treat any
• ther chronic illness, you will find that the

disease of addiction will respond to that treatment just as any other chronic illness would respond.

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Some Useful Websites

• www.painedu.com
• www.projectcork.org
• www.asam.com
• www.globalrph.com
• www.jpain.org
• www.ampainsoc.org

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