• Board Certified Internal Medicine

• Board Certified Hospice and Palliative Care Medicine

• Board Certified Addiction Medicine

• Assistant Professor, University of Virginia

• MGM6V@Virginia.edu

EVALUATING AND TREATING THE PATIENT WITH POSSIBLE SUBSTANCE MISUSE

DISORDERS

Mary G. McMasters, MD

As of May 1, 2009

www.PCSSmentor.orgSAMHSA/ASAM Physician Clinical Support

System877-630-8812

Comprehensive Behavioral Health57 N. Medical Park Drive, Ste 109Fishersville, VA 22939540-941-2504mcmaste1@msu.edu

Educational Goals• KNOW WHAT YOU ARE DIAGNOSING!!!

DIVERSION, SUBSTANCE ABUSE AND ADDICTION ARE NOT THE SAME THINGS

• UNDERSTAND THE STANDARD OF CARE FOR PRESCRIBING CONTROLLED SUBSTANCES (AND SOME NOT CONTROLLED)

• UNDERSTAND THAT PATIENTS WITH THE DISEASE OF ADDICTION OFTEN DO GET BETTER (BELIEVE IT OR NOT!)

Tolerance - Require a higher dose to get the same effect

Dependence - Have withdrawal symptoms if medication is stopped

Abuse - Using the substance to alter mood, “get high”

Addiction - Abuse with psychological dependence on, and craving for, the substance despite repeated adverse consequences. Inability to quit without help.

DIVERSION

• Obtaining mood altering substances under false pretenses and diverting them to other people– To get high– FOR PROFIT.

• DIVERSION IS BIG BUSINESS!!!!!

Source Where Pain Relievers Were Obtained for Most Recent Nonmedical

Use among Past Year Users Aged 12 or Older: 2006

Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown.

1 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”

Bought/Took from

Friend/Relative14.8%

Drug Dealer/Stranger

3.9%

Bought on Internet

0.1% Other 1

4.9% Free from Friend/Relative

7.3%

Bought/Took fromFriend/Relative

4.9%

Drug Dealer/Stranger

1.6%Other 1

2.2%

Source Where Respondent ObtainedSource Where Friend/Relative Obtained

One Doctor19.1%

More than One Doctor

1.6%

Free from Friend/Relative

55.7%

More than One Doctor3.3%

One Physician80.7%

THERE WAS A LOT OF DIVERSION GOING ON DURING

THESE RIOTS:• Underaged drinking (people over 21 were selling

alcohol to minors)• Ketamine was in use (diverted from veterinary

use)• Diverters (dealers) were making a lot of money

(methadone is $1/mg on the street)• Drug dealers VERY SELDOM have the disease

of addiction

SUBSTANCE ABUSE

• “the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological (or social or occupational) problem that is likely to have been caused or exacerbated by the substance.”

THERE WAS A LOT OF SUBSTANCE ABUSE GOING ON

• Fines

• Jail time

• Expelled from MSU

• ANGRY parents

These are effective in convincing substance abusers to quit or to be more responsible.

ADDICTION

• “the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological (or social or occupational) problem that is likely to have been caused or exacerbated by the substance.”

• “persistent desire or unsuccessful efforts to cut down or control substance use.”

Some of these students have the disease of ADDICTION

(they cannot stop abusing mood altering substances without help)

Epidemiology

SUBSTANCE ADDICTION:

A BRAIN DISEASE

Pathophysiology: The Brain

• Elevation of brain dopamine appears to be an essential neurochemical substrate of drug self-administration

• The Mesoaccumbens brain dopamine system appears to be an essential neuroanatomical substrate of drug self-administration

• The Mesaaccumbens brain dopamine system appears to be an essential neuroanatomical substrate of vulnerability to drug self-administration

Con’t

• Brain systems implicated in relapse to drug self-administration after behavioral extinction and pharmacological detoxification of the drug-taking habit

• Drug self-administration in laboratory animals as a screening tool and predictive paradigm in the development of anti-addictive pharmacotherapies

StarvationDehydrationSuffocation

CRAVINGS,Applications of higher order

reasoning to satisfy the cravings

In humans and animals, unlimited access leads to---

• Stimulants alternating bouts of consumption and abuse leading to death

• ETOH alternating bouts of consumption and abuse

• Barbiturates and Dissasociative anesthetics constant use

• Benzodiazepenes constant use

• Opiates constant use

Genetics of Addiction

• Can breed animals for phenotype- drug liking and drug disliking

• Human neuroimaging of DA receptor densities- normal, don’t like amphetamines, deficient- like amphetamines

• Gene transfer in rats- get more DA receptors, decrease drug use

Animal studies

Rat with Addiction

Rat withoutAddiction

GENES =

Rat with Addiction

Con’t

• The genetics of Addiction resemble those of DM type 2 in humans:– Alcohol best studied– Roughly 60% inherited (vs. environment)– Different subtypes– Increased heritability with certain other co-

morbidities

Con’t

-Nicotine also with strong inheritability-Other substances harder to study

BOTTOM LINE:

ADDICTION IS A BRAIN DISEASE WITH PREDICTABLE STEREOTYPICAL BEHAVIORS IN BOTH HUMANS AND ANIMALS

PAIN AND ADDICTION

• Exposure to opioid medications due to “real” pain can lead to the activation of the disease of addiction

• If you’re treating pain, functioning gets better.

• If you’re feeding an addiction, functioning gets worse!!!

HOW TO ACTIVATE THE DISEASE OF ADDICTION:

(2 factors)

GENETIC PREDISPOSITION

PLUS

APPETITIVENESS OF THE SUBSTANCE

(how fast it increases DA in the forebrain)

Examples:

-4 out of 10 Viet Nam Vets were exposed to heroin (VERY addictive) but not all of these developed addiction (3-16%).

-Antibiotics have NO Addictive qualities.

DIFFERENT PATIENTS HAVE DIFFERENT PROPORTIONS

• Large genetic predisposition for addiction– Takes very little to trigger it

• OTC• Ultram• Few exposures

• Little genetic predisposition for addiction– Takes A LOT to trigger it

• Highly addictive substances– Cocaine, nicotine

• MANY exposures

• No genetic predisposition- No addiction

What’s a busy doctor to do?

Universal Precautions for Prescribing Controlled

Substances(this is where the DEA comes in)

1. Diagnosis with reasonable differential

2. Social history which includes assessment of substance use AND family history (and you thought I was just trying to impress you with all that genetic stuff!!!)

3. Rational non-opioid therapeutic trial

4. Pre trial assessment of pain/function

5. Informed consent (agreement)

6. Careful, time limited trial of opioid therapy

Con’t

7. Long term opioid management should be predominantly with long acting opioids (remember those DA receptors!)

8. Reassessment of pain/function and diagnosis

9. Regular assessment of aberrant behavior (ask, UDS, VA monitoring)

10. DOCUMENT, DOCUMENT, DOCUMENT!!!

The common factor between Palliative Care and Addiction treatment is:

FUNCTIONING

• IF YOU ARE TREATING PAIN, FUNCTIONING GETS BETTER

• IF YOU ARE FEEDING AN ADDICTION, FUNCTIONING GETS WORSE

Urine Drug Screens

• Should be a part of any controlled substance agreement

• Should NEVER be done solely based on a patient’s gender, age, race or behavior– You can only pick up substance abusers/diverters

50% of the time based on these

• Diverters/substance abusers make VERY GOOD PATIENTS

• URINE DRUG SCREENS ARE A THERAPEUTIC TOOL!!!!

UDS con’t

• DO THEM!!!!!!!!!!!

• DO THEM ON EVERYONE TAKING CONTROLLED SUBSTANCES (INCLUDING YOUR GRANDMOTHER)

• DO THEM RANDOMLY

• FOLLOW UP ON THEM

What do you do when the UDS isn’t “right”

• What you prescribed isn’t there:– Diversion?

• Professional diverters DO NOT like being caught and generally will “melt away”

– Need more pain meds than they’re getting?• Increase while following functioning closely

– Extortion or threats?

Con’t

• What to do when there are substances in the urine which shouldn’t be there:– Dangerous interactions

• Ex: Benzodiazepines and Opioids

– Meds you didn’t prescribe– Illicit Substances

Con’t

• NEVER miss a chance to counsel a patient to quit a dangerous behavior– Substance abusers CAN quit

• NEVER miss the chance to refer a patient for treatment of the disease of addiction– It is more deadly than HTN, DM, CAD– IT IS TREATABLE

• Even if you don’t want to continue to prescribe controlled substances, don’t abandon your patient.

TREATING WITHDRAWAL

• !!!!! WITHDRAWAL IS NOT THE SAME AS SUBSTANCE ABUSE TREATMENT!!

• HARD WITHDRAWALS DO NOT DISCOURAGE FUTURE SUBSTANCE USE

• REPEATED WITHDRAWALS MAY PREDISPOSE TO MORE SUBSTANCE ABUSE

WITHDRAWAL CON’T

MAKING AN ADDICTED PATIENT GO THROUGH A PROLONGED AND PAINFUL WITHDRAWAL DOES NOTHING TO PREVENT FURTHER SUBSTANCE USE AND IS IMMORAL AND UNETHICAL.

Treatment for Addiction

“This is more than an addict no longer using the substance of abuse. It is active participation in a recovery program.”

Project MATCH:

Cognitive Behavioral Therapy

Motivational Enhancement Therapy

Twelve Step Facilitation

Recovery con’t

• All three equally efficacious. Only 12 Steps accessible to ALL patients

• The more treatment, the better• Inpatient + Intensive Outpatient + Outpatient +

continuing 12 Step participation = 60-80% abstinent at one year (better than DM and HTN)

• Better compliance than patients with DM and HTN

• Relapse common (just like DM and HTN)

Relapse

• Just like diabetes, a relapse can be small (few consequences) or large (many consequences)– Small- one or two uses– Large- long lasting, return to risky behaviors

with serious consequence

• How to deal with a relapse: GET BACK TO BASICS

• NOT THE END OF THE WORLD

RECOGNIZE “CROSS ADDICTIONS”

• Legal or illegal doesn’t make any difference when it comes to addiction-Switching from ETOH to BNZs-Giving up cocaine and going to compulsive sex/shopping/gambling-Quitting smoking and starting compulsive eating-Nicotine may be legal but it is still an ugly

addiction

So, in Summary

• When evaluating the patient with possible Substance Misuse Disorders:– Use correct terminology

• Diversion- a major public health hazard– Discourage through responsible prescribing

• Substance Abuse- a major personal health hazard– Discourage through responsible prescribing– Discourage through education

• Addiction- a chronic treatable disease

Summary con’t

• Addiction– A brain disease– Treatable

• Abstinence counseling– 12-steps most readily available

• Medications– Aids to abstinence counseling

» Buprenorphine, nicotine replacement, naltrexone, varenicline, etc.

– Referral: inpatient tx, Addictionologists, etc.

The End.

Addendums

• “Algorithms for Safe Opioid Prescribing” printed courtesy of Reckitt Benckiser Pharmaceuticals, maker of Suboxone©

References

• 1. All alcohol MAAT information from Johnson, BA, Update on neuropharmacological treatments for alcoholism: Scientific basis and clinical findings, Biochem Pharmacol (2007),doi:10.1016/j.bcp.2007.08.005

• 2. Volpicelli JR, Alterman AI, Hayashida M, O’Brien CP, Naltrexone in the treatment of alcohol dependence, Arch Gen Psychiatry (1992) Nov;49(11):876-80

References con’t

• 3. Anton et al, Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence, The COMBINE Study: A Randomized Controlled Trial, JAMA 2006;295:2003-2017

• 4. Le Foll G, George TP, Treatment of tobacco dependence: integrating recent progress into practice (Clinical report), CMAJ 177.11(Nov 20, 2007):p1373(8).

References con’t

• Benoit Denizet-Lewis, US: An Anti-Addiction Pill? New York Times Magazine, 2006, http://www.mapinc.org/media/297

• Kosten T, Owens SM, Immunotherapy for the treatment of drug abuse, Pharmacology & Therapeutics 108(2005)76-85

References con’t

• Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH posttreatment drinking outcomes J Stud Alcohol. 1998 Jan;59(1)124-5.

• Ling W, Wesson DR, Clinical efficacy of buprenorphine: comparisons to methadone and placebo Drug and Alcohol Dependence 70(2003)S49-S57.

References con’t

• Federation of State Medical Boards

– Report of the Center for Substance Abuse Work Group

– Model Policy Guidelines for Opioid Addiction Treatment in the Medical Office

• Buprenorphine in the Treatment of Opioid Dependence, www.aaap.org

References con’t

• National Survey on Drug Use and Health, http://www.oas.samhsa.gov/2k6/getPain/getPain.htm

• Slides 16 & 17 courtesy of Brian H. Reise, Diversion Group Supervisor DEA, Greensboro Resident Office (336)-547-4219, Ext. 30