Transcript the Powerpoint version

Congressman Tipton’s Opioid
and Heroin Abuse Panel
Discussion
Bob Sammons, M.D., Ph.D.
Mesa Behavioral Medicine Clinic
TMS Solutions
Conflict of interest
• None
•
•
Dr. Sammons received a bachelors and master’s degree from Auburn
University, a PhD in clinical psychology from the University of North Carolina at
Greensboro, and a medical degree from the University of North Carolina at
Chapel Hill. He did a residency in psychiatry at the University of Virginia as well as
a forensic fellowship. While serving in the United States Air Force as a squad
commander and captain, he was selected as one of 5 psychologist to establish the
opiate treatment phase of the drug treatment program for the Department of Air
Force in 1972. For this he receive the Meritorious Service Medal. He has
practiced adult psychiatry in Grand Junction for 28 years. He is 1 of 2 physicians
in town that have received specialist training and a special DEA number that
allows him to prescribe Suboxone treatment for opiate dependency.
Goal
• Fulfill requirements of H.R. 4969, John Thomas Decker Act of 2016
• To educate and prevent addiction in teenagers and adolescents who
are injured playing youth sports and are subsequently prescribed an
opioid
• Make this information available to teenagers who play sports as well
as for their families, sports groups, and health care providers
• Problem: Opioids are better educators than we are (Katie Sammons,
M.A., Ph.D., Pend)
Impetus for the
John Thomas Decker Act of 2016
• John Thomas Decker died at age 30 from an opioid overdose
• He was a talented young athlete, lettering in three different sports in
high school before going on to play lacrosse at Cornell
• He suffered an injury playing a pick up game of basketball
• Undergone multiple surgical repairs on his or anterior cruciate
ligament (ACL)
• Eventually was place on an opioid medication
• Became “hooked” on the opioid
• Eventually sought out cheaper and more easily assessable heroin
• Died of respiratory depression from an overdose of the opioid
Problem
• You can play football or you can avoid being hurt. But you can’t play
football and avoid being hurt.
• Like the Deadliest Catch TV Show. There is a 100% injury rate.
• If you are seriously hurt, you see a physician to relieve your pain and
suffering.
• You can be told the government does not want you to be given
medicine that will take your pain away.
• Or you can be given an opioid that will take your pain away but
possibly put you on the path of a miserable and potentially life
threating addiction.
Mechanism of Action of Addiction
• At lower doses opiates causes analgesic pain relief
• And at higher doses opiates produce a rush of euphoria or dream like
state
• opioids overstimulate the brain’s reward circuit and trigger a large
release of dopamine
• Dopamine is often called the pleasure molecule
• Repeated overstimulation of the brain’s reward circuit numbs the
response in the brain’s pleasure center (nucleus accumbens)
• To attempt to maintain homeostasis, the pleasure center releases
dynorphin, which inhibits the stimulation of this area
• By turning down the stimulation
• the addict will feel less pleasure from the drug
• the high won’t be as rewarding.
• the addict will require more and more stimulation to get the same level of
reward
• Eventually, the addict needs to take the drug just to feel normal.
Cravings
• Cravings occur through stimulation of an area called the ventral
tegmental area (VTA)
• Here the release of dopamine sensitizes the area of the VTA making it
more sensitive and easier to activate
• With repeated drug use the dopamine causes more cravings and over
time the cravings become so strong they can no longer be resisted
Reduced self control
• The prefrontal cortex plays a major role in inhibiting behavior
suggested by the more primitive reward circuit
• prefrontal cortex is the logical, rational circuit that understands consequences
and that inhibits inappropriate behavior
• With repeated drug use the prefrontal cortex is impaired and reduces
the addict’s ability to exhibit self-control and override drug craving
becomes weaker and weaker
Treatment
• Recidivism of addicts who stop on their own is 93%
• Lots of articles on opioid problem
• New England Journal of Medicine, April 2016, A Proactive Response
to Prescription Opioid Abuse
• “We will continue to support abuse-deterrent formulations and
encourage development of more effective abuse-deterrent features”
Abuse-deterrent medications
• I remove demons from people’s mind and never get a thank you. When I
prescribe Suboxone, people hug my neck and thank me for giving them their life
back.
• Buprenorphine/Naloxone (Suboxone, Zubsolv)
• I advocated for years for this medicine to be the first medicine used after the
failure of a NSAID
• Requires a special DEA number to prescribe of opioid dependency
• Any physician can prescribe for pain control
Abuse-deterrent medications
• It is a partial agonist
• You don’t develop tolerance
• It has a ceiling effect
• addicts can’t get high
• once receptors are full, there is no place for opioids to bind
• Can’t overdose - unless you are on a benzodiazepine or alcohol
• Competes for the opiate receptor site
• competitive agonist
• Suboxone is an opiate
• Short Acting VS Long Acting 24-36 hours
•
No roller coaster ride
• Minimum of 3 days to tell what amount keeps you stable
rTMS in the treatment of addiction
• The rationale to use rTMS as a treatment for substance addiction and
craving is that the DLPFC, which plays a major role in top-down
inhibitory control mechanisms and reward mechanisms, is
dysfunctional in these disorders
• Guidelines evidence-based guidelines on the therapeutic use of
repetitive transcranial magnetic stimulation (rTMS) Clinical
Neurophysiology 125 (2014) 2150–2206
Acknowledgements
• Mechanism of action in addiction heavily quoted from Thad Polk,
Ph.D., The Addictive Brain Course Guide, The Great Courses
• I have donated a CD and DVD copy of this course to the Mesa County
Library as well as Mesa County Community Corrections