Addictions 101: Understanding, Recognizing Download

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Addictions 101:
Understanding, Recognizing, and
Treating the Disease State
www.OverdoseFreePA.pitt.edu
Substance Use Disorder Treatment Professional Curricula
Core Component 1
© 2014, Overdose Prevention Coalition
The OverdoseFreePA website is brought to you
by the Overdose Prevention Coalition, a
collaborative between:
The Pennsylvania Department of Drug and Alcohol Programs (DDAP)
The Single County Authorities (SCAs) of:
Allegheny County
Blair County
Bucks County
Butler County
Dauphin County
Delaware County
Westmoreland County
The Allegheny County Medical Examiner’s Office
The Program Evaluation Research Unit, University of Pittsburgh School of Pharmacy
The project is supported by a generous grant from the
Pennsylvania Commission on Crime and Delinquency.
Background Photo for Slide Set by Jason Pratt from Pittsburgh, PA (Trees and light)
[CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia
Learning Objectives
• Describe the etiology of alcohol and substance
use disorders.
• Describe the incidence and societal burdens of
substance use disorders.
• Discuss the diagnostic criteria for alcohol and
other drug abuse and dependence.
• Measure the economic outcomes and cost benefit
of problematic substance use prevention,
intervention, and substance use disorder
treatment.
• Discuss the benefits that Screening, Brief
Intervention and Referral to Treatment have in
different medical settings.
SAMHSA National Survey
2012 National Survey on Drug Use and Health
• 23.9 million people over 12 years are current
illicit drug users (9.2% of population over 12
years old)
• 52.1% of individuals over 12 years report being
current drinkers
• Of all individuals over 12 years who drink
– 23% binged in the last month
– 6.5% participated in heavy drinking
Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health:
Summary of National Findings, NSDUH Series H-46, HHS Publication No.(SMA) 13-4795.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013
SAMHSA National Survey
Past Month Use of Selected Illicit Drugs among Youths
Aged 12 to 17: 2002-2012
Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health:
Summary of National Findings, NSDUH Series H-46, HHS Publication No.(SMA) 13-4795.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013
SAMHSA National Survey
Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among
Persons Aged 12 or Older: 2002-2012
Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health:
Summary of National Findings, NSDUH Series H-46, HHS Publication No.(SMA) 13-4795.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013
SAMHSA National Survey
Source Where Pain Relievers Were Obtained for Most
Recent Nonmedical Use among Past Year Users Aged 12
or Older: 2011-2012
Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health:
Summary of National Findings, NSDUH Series H-46, HHS Publication No.(SMA) 13-4795.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013
Overview of Substance and Drug Use
Past-Year Initiates for Specific Illicit Drugs
Among Persons Age 12 or Older, 2008
Source: Substance Abuse and Mental Health Services Administration. (2009). Results From the
2008 National Survey on Drug Use and Health: National Findings Rockville, Maryland.
Overdose Deaths in Pennsylvania
DRUG OVERDOSE DEATHS IN PENNSYLVANIA
Number of
PA
Year
Deaths
Population
Rate per 1,000
2011
1,909
12,742,886
15.4
2010
1,550
12,702,379
12.5
2008
1,522
12,448,279
12.6
2006
1,344
12,440,621
11.2
2004
1,278
12,406,292
10.6
2002
895
12,335,091
7.5
2000
896
12,281,054
7.4
1998
628
12,001,451
5.4
1996
630
12,056,112
5.4
1994
596
12,052,410
5.1
1992
449
11,995,405
3.8
1990
333
11,881,643
2.7
Based on Pennsylvania Department of Health data, overdose deaths
have been on the rise over the last two decades with an increase in
the rate of death from 2.7 to 15.4 per thousand Pennsylvanians
Overdose Deaths in Pennsylvania (cont’d)
In 1990, note for the 64 grey counties, the death rate is too low to be
accurately counted, at less than 3 deaths per 1,000 citizens. The state
average is 2.7 deaths per 1,000 citizens, so any colored counties are above
average, while grey is below average.
Overdose Deaths in Pennsylvania (cont’d)
In 2000, note for the 52 grey counties, the death rate is too low to be
accurately counted, at less than 3 deaths per 1,000 citizens. The state
average is 7.4 per 1,000 citizens, so the light blue, yellow and orange
counties are above average, while grey and dark blue are below average.
Overdose Deaths in Pennsylvania (cont’d)
In 2011 (on right), note for only 35 grey counties, the death rate is too
low to be accurately counted, at less than 3 deaths per 1,000 citizens.
The state average is 15.4 per 1,000 citizens, so the yellow and orange
counties are above average, while grey and dark blue are below average.
Heroin-Related Overdose Deaths in Pennsylvania
Heroin Only and Multidrug Toxicity Deaths
1400
1248
1200
1000
Heroin only
728
800
584
Heroin and other drugs
600
400
200
324
47
356
273
107
*Projection based on overdose
data through July
159
25
0
2009
•
2010
2011
2012
2013
(Projected)
Based on Pennsylvania Corners Association (PCA) reports in 43 counties, heroin and
heroin related deaths have been on the rise for the past 5 years (PCA, 2013)
•
Between 2009 and 2013 there 2,929 heroin related overdose deaths identified by county
coroners.
drugs.
Of these, 490 (17%) were heroin only, while 2,439 (83%) involved multiple
Why Drug Misuse Occurs
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–
–
–
–
–
–
Experimental
Social-recreational
Circumstantial-situational
Adaptive
Self-medication
Intensive
Compulsive
Unintentional
Etiology of Chemical Dependency
•
Social rebellion
– Peer group influence and questioning societal values
•
Symptom relief
– Self medication hypothesis
•
Learned behavior
– Drive – cue-response – reinforcement
– Tolerance – dependency-response – reinforcement
•
Personality traits
– Addictive personality
•
Disease
Abuse Potential
• ALL drugs and alcohol
stimulate the mesolimbic
dopamine system which is
the brain’s reward center
• Rapid absorption,
distribution, and onset of
action enhance abuse
potential for the user
By MartijnL (Own work) [CC-BY-SA-3.0-nl
(http://creativecommons.org/licenses/bysa/3.0/nl/deed.en)], via Wikimedia Commons
By Angie Garrett from Ridgely, USA [CCBY-2.0
(http://creativecommons.org/licenses/by
/2.0)], via Wikimedia Commons
FDA Warning Labels
In September 2013 the FDA updated the warning
labels on long acting opioid products.
The new labeling adds: "Because of the risks of addiction,
abuse and misuse with opioids, even at recommended doses,
and because of the greater risks of overdose and death with
extended-release opioid formulations, reserve [Trade name]
for use in patients for whom alternative treatment options
(e.g., non-opioid analgesics or immediate-release opioids) are
ineffective, not tolerated, or would be otherwise inadequate to
provide sufficient management of pain."
Progression to Dependence
By Sander van der Wel from Netherlands (Depressed Uploaded by russavia)
[CC-BY-SA-2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia
Commons
Initiation
•Escape-avoidance
•Appropriate
Prescription Use
Continuation
•Loss of problemsolving capacity
Maintenance
•Rationalization
•Projection
Dependence
•Use to avoid
negative physical
and psychological
consequences
DSM-IV Abuse
Maladaptive pattern of use leading to clinically
significant impairment manifesting one or more of
the following within a
12-month period:
• Behavioral impairment
• Use in hazardous situations
• Legal problems
• Recurrent use in spite of social and interpersonal
problems
DSM-IV Dependence
Maladaptive pattern of use leading to clinically
significant impairment manifesting three or more
of the following within a 12-month period:
• Tolerance
• Withdrawal
• Using more than intended
• Preoccupation with use
• Narrowing of non drug use activities
• Continued use in spite of negative consequences
• Compulsive use
DSM-V Substance Use Disorder
A major overhaul of the DSM-IV criteria for substance use includes the
following:
• Substance Use Disorder (SUD) is a single disorder, measured on a
continuum from mild to severe, that combines the DSM-IV abuse and
dependence criteria with the following two exceptions:
 DSM-IV recurrent legal problems has been removed
 New criterion for craving or a strong desire or urge to use has
been added
• Each specific substance is addressed as a separate use disorder (e.g.
alcohol use disorder, opiate use disorder)
• Cannabis and Caffeine withdrawal are new for DSM-V
• Gambling disorder has been added
DSM-V Substance Use Disorder
• SUD is accompanied by criteria for intoxication,
withdrawal, substance/medication-induced disorders and
unspecified substance-induced disorders.
• The severity of SUD in DSM-V is based on criteria
endorsed:
 2-3 – mild disorder
 4-5 – moderate disorder
 6 or more – severe disorder
• Helps define SUD as a continuum and removes confusion
regarding dependence with “addiction” when in fact
dependence can be a normal body response to a
substance.
• Additional modifiers and specifies exist as well.
Continuum of Aberrant
Prescription Drug Misuse
Less Serious
More Serious
•
Aggressively complaining
about need for medication
•
Claiming multiple pain
medication allergies
•
Asking for specific medicine
by name
•
Visiting multiple docs for
controlled Rx
•
Asking for non-generic
medication
•
Hoarding medication
•
Frequent calls to clinic
•
Using controlled substance
for non-pain relief
purposes (e.g. to enhance
•
•
Requesting to have dosage
increased
Taking a few extra,
unauthorized doses on
occasion
mood, sleep)
Continuum of Aberrant Prescription
Drug Misuse (cont’d)
Most Serious
More Serious
•
•
•
•
•
•
•
Frequent unscheduled clinic
visits for early refills
Consistent disruptive behavior
upon arrival to clinic
Obtaining cont meds from
family
Pattern of lost or stolen Rx
Anger/irritability when
questioned closely about pain
Unwilling to consider others
medication or nonpharmacologic treatments
Frequent unauthorized dose
escalation after being told this is
inappropriate
•
•
•
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Injecting oral formulation
Forging Rx
Unwillingness to sign Rx
agreement
Selling
Aliases
Refusal of workup
More concern about drug than
medical problem (past 2-3 visits)
Buying/illicit obtaining
“Targeting” a specific provider
Deterioration of function due to
Rx
Chemical Dependency:
Epidemiology
Alcohol dependence
• Annual Prevalence; males=10.7%, females=3.7%
• Lifetime Prevalence; males 20.1%, females=8.2%
Drug dependence
• Annual Prevalence; males=3.8%, females=1.9%
• Lifetime Prevalence; males=9.2%, females=5.9%
Data from National Comorbidity Survey, Kessler et al, Arch Gen Psych, 54(4). 1997. p313-321
Chemical Dependency:
Pathophysiology
• Medial forebrain
bundle (MFB) or
mesolimbic dopamine
system (is involved
with dependence)
• This system is also
known as the “pleasure
pathway”
Areas of the Brain Affected by SUD
Humanistic
–Reintegrate into daily life without the burdens of
drug use
–Prevention of or increased compliance with
treatment in coexisting risk associated diseases
–“De-stigmatize” the patient
–Increase patient’s quality of life through
employability and responsibility
–Increase the quality and availability of services
provided to patients
Societal
• Decrease in crime and drug diversion
• Decrease in cost burden to health care system
• Increase in work productivity and/or decrease in
absenteeism
Economic
• Decrease in substance-related treatment
admissions
• Decrease utilization of emergency and chronic
services (trauma, HIV related, hepatitis related, TB
related, social services, criminal justice)
• Cost of agonist therapy vs. cost of repeated drug
treatment
Economic Outcomes
Cost of Untreated Misuse
•
Incarceration = ~$15,000-47,000/yr per inmate
•
Untreated addiction = ~$30,000-200,000/yr
Cost of Treatment
•
Buprenorphine outpatient treatment = ~$3,500-4,500/yr
•
MMT = ~$2,800-7,300/yr
•
Outpatient drug treatment = ~$3,500-12,000/course of tx
•
Inpatient residential treatment = ~$7,500-30,000/course of tx
CALDATA 1991-1993
Cost Benefit of Treatment
California Drug and Alcohol
Treatment Assessment Study, 1994
• For every $1 spent on treatment, $7 is realized
through decrease in crime, employability, decrease
in utilization of emergency and social services
• Continual abstinence 3 and 5 years after treatment
approached 50% for all treated patients
Cost Savings from Substance
Abuse Services
Criminal Justice System
Impact
Health System
Savings
Clinical
• Buprenorphine and Naloxone prescription
and overdose impact.
• Substance use training of Health Care
Professionals to improve patient care.
• Screening, Brief Intervention and Referral to
Treatment (SBIRT)* implementation that
motivates patients to change.
TRAINING FOR
HEALTH CARE
PROFESSIONALS
Physician Training
• Center on Addiction and Substance Abuse (CASA,
Columbia University) Survey 2000
– 94% of primary care physicians (pediatricians
excluded) failed to include substance abuse
among the five diagnoses they offered when
presented with early signs and symptoms of
substance abuse
– 41% of pediatricians failed to diagnose drug
abuse when presented with a classic description
of an adolescent patient with symptoms of drug
abuse
Center on Addiction and Substance Abuse (CASA, Columbia University) Survey, 2000
National Institute on Drug Abuse (NIDA) Website; http://www.nida.nih.gov/infofacts/costs.html
Physician Training (cont’d)
• 54% of patients said their PCP did nothing
about their substance abuse
– 43% – PCP never diagnosed it
– 11% – Believe their PCP knew about their addiction and
did nothing about it
• Less than one third (32%) carefully screen
for substance abuse
• 54% of patients agreed that PCPs do not
know how to detect addictions
Center on Addiction and Substance Abuse (CASA, Columbia University) Survey, 2000
National Institute on Drug Abuse (NIDA) Website; http://www.nida.nih.gov/infofacts/costs.html
Physician Training (cont’d)
• 54% say that doctors prescribe drugs that can be
dangerous to individuals
– 30% of patients said their PCP knew about their
addiction and still prescribed psychoactive drugs such
as sedatives or valium.
• Average patient was abusing alcohol, pills,
and/or illegal drugs for ten years before entering
treatment
• 74% of patients said their PCP was not involved
in their decision to seek treatment and 17% said
the PCP was involved only “a little”
Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. 2000
Reasons for Misdiagnosis
• Lack of education in medical school
• Skepticism about treatment effectiveness
– Only 2 to 4% of physicians consider treatment for
substance abuse very effective
– In contrast the majority of physicians consider
treatment for diabetes and hypertension very effective
• Patient resistance to discuss
• Discomfort discussing substance abuse
• Time constraints
• Fear of losing patients by talking about addiction
• Lack of insurance coverage
Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. 2000