Transcript opioids, tobacco, and marijuana - eapa

George Kolodner, M.D.
Kolmac Clinic
[email protected]
October 6, 2011
Outline
1. Prescription Opioids
 Success problems with buprenorphine
2. Marijuana
 Medicalization
3. Nicotine
 Treating it as an addiction
1. Prescription Opioids:
Success Problems With Buprenorphine
• Improved clinical results when patients stay on
buprenorphine longer
• Physicians reaching 100 patient limit
• Some diversion
– Better treatment results for patients who used street
buprenorphine
• Resistances within the addiction field
– Professional: 28 day residential treatment centers
– Recovery community: Narcotics Anonymous
Buprenorphine vs. Methadone
in Pregnancy
 Same incidence of neonatal abstinence syndrome
(NAS)
 Less severe NAS with buprenorphine
 89 % less medication
 43% less hospital days
 More discontinuation of buprenorphine than
methadone because of dissatisfaction with medication
Changes in Marijuana Use
 Utilization is up among high school students
 2010: reversal of downward trend

www.monitoringthefuture.org
 Purity is up
 Based on DEA street buys
Marijuana: Negative Effects
• Evidence for residual negative impact on executive
cognitive functions
• Attention, concentration
• Ability to plan, organize, solve problems, make decisions
• Inhibition and impulsivity
• Physical addiction documented
• Increased blood pressure, insomnia, irritability, anxiety
• DSM-5 has new diagnosis for “Cannabis Withdrawal”
Possible Changes in Legal Status
• Current DEA Controlled Drug Status
– Marijuana: Schedule 1
– Synthetic THC (dronabinol, “Marinol”): Schedule 3
• Decriminalize
– Manage offenses with fines instead of incarceration
• Legalize for recreational use
– Regulate and tax like alcohol
• Legalize for medical use (“medical marijuana”)
– Exists in 15 states plus D.C.
Arguments For and Against
Medical Marijuana
• FOR: People are suffering from medical conditions
that respond to smoked marijuana and no other
medication, including dronabinol.
• AGAINST: Marijuana is a complex substance taken via
a high potency route of administration. It should
therefore be subjected to the same quality standards
and dosing studies as any other pharmaceutical,
dispensed through traditional pharmacies, and
regulated by the FDA.
DC Medical Marijuana Regulations
Qualifying medical condition means:
• (a) Human immunodeficiency virus;
• (b) Acquired immune deficiency syndrome;
• (c) Glaucoma;
• (d) Conditions characterized by severe and persistent
muscle spasm, such as multiple sclerosis;
• (e) Cancer; or
DC Medical Marijuana Regulations
**(f) Any other condition, as determined by rulemaking, that is:
•
(1) Chronic or long lasting;
•
(2) Debilitating or interferes with the basic functions of life; and
•
(3) A serious medical condition for which the use of medical
marijuana is beneficial:
•
(1) cannot be effectively treated by any ordinary medical or
surgical measure; or
•
(2) For which there is scientific evidence that the use of medical
marijuana is likely to be significantly less addictive than the
ordinary medical treatment for that condition
Continued Legal Ambiguities
 DOJ Memo, 10/09: Federal government would not act
against marijuana in states where its use for medicinal
purposes was legal
 DOJ Memo, 6/11: “Persons who are in the business of
cultivating, selling, or distributing marijuana, and
those who knowingly facilitate such activities, are in
violation of the Controlled Substances Act, regardless
of state law.”
Implementation Problems
 Qualifying medical conditions
 California: “pseudo medicalization” = de facto
recreational legalization
 Dosing and purity
 Relationship with physician
 Addressing drugged driving
 California: “thug factor”
Possible Resolution
 Keep specific diagnostic indications
 Remove “catch all” category but allow for exceptions on
a case by case basis
Applying What We Know About Substance Use
Disorders to the Biggest Addiction of Our Time
Annual Mortality:
The Elephant in the Addiction Room
 USA
 Nicotine: 440,000
 Alcohol: 100,000
 All other drugs: 10,000
 Nicotine mortality worldwide
 Kills 50% of the people that use it
 2000: 4.9 million
 Projected by 2020 to kill 10 million people and become
the number one cause of death
Secondhand Smoke: Annual Impact
 Smoke from burning end of cigarette is more toxic
than smoke that is inhaled
 53,000 deaths of non-smokers
 Compares with 11,000 deaths from drunk drivers
 35,000 from heart attacks
 3,000 from lung cancer
 Young children are especially sensitive
 Under 18 months: 300,000 cases of pneumonia and
bronchitis
 26,000 develop asthma
Correcting Mistaken Beliefs
 Lung cancer is not the biggest medical danger
 Only 15% of smokers develop lung cancer
 Tobacco is the #1 risk factor for heart attacks

Risk is reduced by 50% one year after quitting
 Tobacco is leading cause of COPD
 Nicotine is addicting but not toxic
 No major medical consequences from nicotine except
slower wound healing after surgery

Nicotine patch does not slow healing
Tobacco Utilization in USA
 Reduced in adults
 1964: 40%  Now: 20.6%
 Higher in people with substance use disorders
 Alcoholics: 34% to 56%
 Drugs: 52% to 68%
 Highest in patients in treatment for SUDS
 65% to 85% (especially methadone)
 Tobacco shortens life span of alcoholics in recovery
Paying Lip Service to Addiction:
Changing Our Language
 Tobacco user  nicotine/tobacco addict
 Smoking cessation  tobacco addiction rehabilitation
 Ex-smoker  recovering smoker
Similarities to Other Addictions
• Continued use despite adverse consequences
• Genetically influenced
– Rapid metabolizers more susceptible to physical
dependence than slow metabolizers
• Withdrawal symptoms are acute and protracted
• Relapses are common and occur in response to the
standard 3 triggers:
– Exposure to substance
– Cues (conditioned learning associations)
– Stress
Differences from Other Addictions
• Greater certainty of toxic effect but more extended
•
•
•
•
length of time to develop
12 step support (Nicotine Anonymous) struggles
Greater tolerance of use by recovery community
Research money is managed by National Cancer
Institute not National Institute of Drug Abuse
Insurance coverage is very limited
The Harder Way
 Impulsive stopping
 Inadequate medication for withdrawal
 Uninformed about drug addiction
 Isolated and secretive
 Non-intensive treatment programs
 Smoking cessation program: think DWI program
The Easier Way
 Planned quit date
 Open disclosure to smoking and non-smoking
relatives and friends
 Adequate nicotine replacement treatment
 Intensive group based rehabilitation
 Use traditional addiction treatment concepts
 Continued care group therapy
Medication Options
 “Nicotine replacement” (detoxification)
 Long acting: patch
 Short acting



Non-prescription: gum, lozenges
Prescription: nasal spray, “inhaler”
Electronic cigarette: unregulated and not recommended
 Wellbutrin/Zyban (buproprion)
 Chantix (varenicline): nicotine receptor agonist
 Over-reaction about causing depression and heart
problems
Mayo Clinic Treatment Program
 Higher doses of multiple medications for 3 to 6 months
or more
 Remove withdrawal as an issue
 Standard recommendations are inadequate
 Fear of nicotine toxicity is misplaced
 Use for as long as it takes

“This is not an infectious disease.”
 8 day residential program: 52% 1 year quit rate
 No intensive outpatient programs exist
Integrating Treatment of Tobacco
Addiction Into Addiction Programs
 Challenging the belief that this will interfere with
recovery
 Addiction treatment programs as enablers of tobacco
addiction
 Most users express the desire to quit
 How to address this and respect the desire of others not
to quit

Importance of not activating negative side of ambivalence
 Kolmac pilot program