Transcript Making Sense of Addiction: Part I: Use/Abuse

Making Sense of Addiction
The Continuum:
Use/Abuse/Dependence/Legal/Ilegal
James Finch, MD
NC Society of Addiction Medicine
NC Governor’s Institute on Alcohol and Substance Abuse
Changes By Choice, LLC
Durham, NC
PSYCHOACTIVE DRUGS OF ABUSE
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Nicotine
Alcohol
Marijuana and hashish
Cocaine, amphetamines, MDMA (“ecstasy”)
Heroin, opioid analgesics (pain pills)
Benzodiazepines, barbituarates
Inhalants (solvents, gases, nitrous)
Hallucinogens (LSD, mescaline, psilocybin)
Other: Ketamine/PCP/DXM/steroids
NEXT?
Deaths Related to Drug Use
(US Centers for Disease Control and Prevention)
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tobacco
>430,000/year
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alcohol
100,000/year
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illicit drugs
15,000/year
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abuse of Rx meds
escalating
Commonly Abused Prescription Medications
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Ranking of common classes of abused prescription medications
in terms of frequency and public health impact:
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Opioid analgesics
 Hydrocodone (Vicodin)
 Oxycodone (Percocet, Oxycontin)
 Methadone (Dolophin)
Benzodiazepines
 Alprazolam (Xanax)
 Clonazepam (Klonopin)
Stimulants
 Amphetamine (Adderal)
 Methylphenidate (Ritalin)
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Grams/100,000 people
US Therapeutic Opioid Use
15,000
Oxycodone
Hydrocodone
Morphine
Methadone
12,000
9,000
6,000
3,000
0
1997
1998
1999
2000
Manchikanti L, Singh A. Pain Physician. 2008;11(2 Suppl):S63-S88.
2001
2002
2003
2004
2005
2006
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Psychotherapeutic Agents: Increasing Non-medical Use
New Users, thousands
2,500
Pain
relievers
2,000
1,500
1,000
Tranquilizers
Stimulants
500
Sedatives
0
1965
1970
1975
1980
1985
1990
1995
2000
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2001 National Household Survey on Drug Abuse.
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2002. http://www.oas.samhsa.gov/nhsda/2k1nhsda/vol1/CHAPTER5.HTM#fig5.3. Accessed April 23, 2008.
Trends In Emergency Department Mentions
Crude rate per 100,000
Epidemics of Unintentional Drug Overdose
Deaths in the US: 1970-2006
10
9
8
7
6
5
4
3
2
1
0
Prescription drugs
Crack cocaine
Heroin
'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06
Year
Len Paulozzi, MD, MPH
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
Unintentional Deaths in NC
Due To Prescription Drugs
900
800
798 826
708
700
650
636
589
600
500 466
400
300
DEATHS
200
100
0
2003
2005
2007
2009
Source: NC State Medical Examiner’s Office
New Illicit Drug Use in US: 2006
2,500
New users, thousands
2,150
2,063
2,000
1,500
1,112
1,000
500
977
860
845
783
267
264
91
69
0
Marijuana
Cocaine
Stimulants
Sedatives
Pain
Tranquilizers
Ecstasy
Inhalants
LSD
a
Relievers
a 533,000
Heroin
PCP
new nonmedical users of oxycodone aged ≥12 years.
Past year initiates for specific illicit drugs among people aged ≥12 years.
LSD, lysergic acid diethylamide; PCP, phencyclidine.
Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2006 National Survey on Drug Use and Health.
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Department of Health and Human Services Publication No. SMA 07-4293; 2007.
We Are a Drug Using and Abusing Culture
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Alcohol
Tobacco
Caffeine and other stimulants
Sedatives
Tranquilizers
Analgesics/pain pills
Illicit drugs
A Long Cultural Tradition of
Seeking Relief with Medication
“to lull all pain and
anger and bring
forgetfulness
of sorrow…”
Homer: The Odyssey
JWF: The Vintage Image Gallery
Drugs Use Extends Along a Continuum from Low
Risk Use to Abuse and Dependence
PROBLEMS
Dependence
5%
None
35%
Moderate
45%
At-risk Abuse
7%
8%
USE
Alcohol use in primary care patients > 18 years old
A Guide to SA Services for Primary Care Clinicians, SAMHSA, 1997
Why do people start using drugs?
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To feel good: get “high” or “buzzed” or “altered”
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To avoid emotional pain, relax or deal with stress: “chill”
or “mellow out”
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To perform better, activate, energize or enhance: “rev” or “amp up”
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To be part of a group, socialize, conform: “fit in”
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Medical treatment of physical pain or psychiatric illness: “get relief”
Why do people keep using or escalate
their use of drugs?
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Previous reasons with expansion into other domains
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Narrowing of behavioral alternatives/increased reliance on drug
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Maintaining “hedonic tone”
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Avoiding physical withdrawal
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What’s “good” about using seems to outweigh what’s
“not so good”
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Denying or ignoring risk or problems
Types of Risks
Associated with Drug Abuse
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Too much for too long risk:
The more and the longer you use, the more likely you are to
have problems.
Ex: Alcohol and liver disease
Marijuana and lung disease
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Any use at all risk:
The characteristics of the drug or how it is used mandate risk
at any level of use.
Ex: Cocaine and cardiac risk
Injecting behaviors and infectious disease risk
Drinking/drug use and trauma risk
Risks Associated with
Prescription Medication Abuse
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Cognitive and/or psychomotor impairment
Danger of combining with other drugs and/or alcohol
Accidental overdose
Physical dependence and withdrawal risks
Over-reliance on for “chemical coping”
Relative Risk Related to
“Controlled Medications”
DEA Scheduling of medications is related to
perceived relative potential for abuse:
Schedule 1: Heroin, LSD, MDMA
Schedule 2: Methadone, oxycodone, amphetamines
Schedule 3: Hydrocodone, buprenorphine
Schedule 4: Benzodiazepines, Ambien, Provigil
Schedule 5: Cough meds with codeine
Schedule 6: Marijuana (NC)
Signs of Progression to Drug Abuse
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Development of recurrent pattern of problems related to the
use of the particular drug or drugs:
Emotional/Physical
Interpersonal/Social
Occupational/Legal
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Escalating use of the drug
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Continued use of the drug in spite of these problems
Diagnosis of Dependence
on Alcohol or Other Drugs
Maladaptive pattern of use leading to clinically
significant impairment or distress, manifested within
a 12-month period by at least 3 of the following:
1.
Tolerance
2.
Withdrawal
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Loss of control over amount consumed
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Preoccupation with controlling use
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Preoccupation with related activities
6.
Impairment of social, occupational, or
recreational activities
7.
Use is continued despite persistent problems related to use
DSM-IV-TR. American Psychiatric Association: Washington, DC; 2000.
Compared with “Physical” Dependence
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Withdrawal syndrome when the drug is withdrawn acutely.
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May or may not be associated with increasing doses and
increasing tolerance to the drug.
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May or may not be associated with abuse of
the drug.
Opioid Withdrawal
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Anxiety/Restlessness
Rhinorrhea
Dilated pupils
Nausea/Diarrhea
Abdominal cramps
Muscle spasms - jerking/restless legs:
“kicking the habit”
Piloerection - goose-bumps:
“going cold turkey”
Case Discussions
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What do issues of use vs abuse vs dependence mean in
the setting of DTC (“But alcohol is legal isn’t it...”)?
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How do these issues present in the setting of “recreational
drug use” (“But that’s not my drug of choice...”)?
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How do these issues present in relation to prescribed
drugs with abuse potential (“But I’ve got a prescription for
the Xanax...”)?