Download What is the Block Grant? - Florida Alcohol and Drug Abuse Association

IV Drug Use: Evaluation, Treatment
and Block Grant Requirements
Raymond Pomm, MD Vice President of Medical Services
Heather Clavette, MA CAP Senior Director of MAT and Outpatient
Services
This product is supported by Florida Department of Children and Families
Substance Abuse and Mental Health Program Office funding.
What is the Block Grant?
• Noncompetitive grant
• SAMHSA responsible for 2 programs
– Substance Abuse Prevention and Treatment Block Grant
(SABG)
– Community Mental Health Services Block Grant (MHBG)
• Provides federal funds and technical assistance to
assist agencies with priority populations in
obtaining and sustaining substance abuse and
prevention services
What are Priority Populations?
•
•
•
•
Pregnant injecting drug users
Pregnant substance abusers
Injecting drug abusers
HIV/TB positive drug abusers
Common Drugs of Abuse
•
•
•
•
•
•
Alcohol
Tobacco
Marijuana
Inhalants
Cocaine/Stimulants
K2, Spice
•
•
•
•
•
•
•
Club Drugs (i.e., ecstasy, GHB)
Hallucinogens
Opioids
Sedative hypnotics
Sports Drugs (i.e., steroids)
Bath Salts
Krokodil (not common yet)
Opioids and Stimulants
OPIOIDS
(OPIATES?)
OPIOIDS
Compounds with agonist effects at the mu opioid
receptor:
 Opiates: natural substances derived from opium:
morphine, codeine and thebaine (paramorphine,
similar to both morphine and codeine used as a
base compound for many semi-synthetic opioids).
 Semi-synthetic opioids: modifications of a
naturally occurring opiate: heroin from morphine;
buprenorphine and oxycodone from thebaine.
 Synthetic opioids: fully synthetic compounds:
methadone and fentanyl.
Historical Perspective
• Civil War: Introduction of the hypodermic needle and
morphine analgesia.
• Harrison Act (1914): prohibition on prescription of
narcotics (opioids) to addicts:
 Many physicians prosecuted/fears of opioid
prescribing
 Increased drug trafficking and crime associated
with opiate (heroin) and cocaine abuse
• 1974: 1st methadone maintenance program for opioid
addiction.
• DATA 2000: office-based treatment of opioid
dependence with buprenorphine.
Harrison Act
"An Act to provide for the registration of, with
collectors of internal revenue, and to impose a
special tax on all persons who produce, import,
manufacture, compound, deal in, dispense, sell,
distribute, or give away opium or coca leaves, their
salts, derivatives, or preparations, and for other
purposes." The courts interpreted this to mean that
physicians could prescribe narcotics to patients in
the course of normal treatment, but not for the
treatment of addiction.
Abuse of Prescription Opioids
• Since 1999: 300% increase in the sales of opioids in
U.S.
• 2008: surge in deaths from overdoses (14,800); more
than for heroin and cocaine combined.
• 2009: 475,000 emergency department (ED) visits for
adverse events related to misuse of opioids (doubling in
5 years).
• CDC: Mixing of drugs was found in half of prescription
opioid-related deaths.
• Past year heroin use increased from 373,000 (2007) to
669,000 (2012).
Source: CDC, 2011
You Will Be Responsible
• Prescription opioids have climbed 300% in the
last decade.
• 46 people per day; 17,000 per year die from
overdoses. That’s up more than 400% from
1999.
• For every death, more than 30 people are
admitted to the ED because of opioid
complications.
Source: CDC, 2015
Psychostimulants
Cocaine History
• Plant: Erythroxylon coca. Shrub grows in Andes.
Used for millennia. Contains 0.5% cocaine.
• Cocaine isolated by Gaedcke 1855
• Local anesthetic use 1884
• Freud: Uber Coca 1884
• Harrison Act: 1914
• Epidemics in 1920’s and 1970’s
• Crack in mid-80’s until present
Amphetamine History
• Amphetamine first synthesized 1887;
methamphetamine in 1918
• 1st available in US as Benzedrine inhaler
(OTC) 1932
• Widespread availability for nonmedical uses
through the 1960’s
• Tighter regulation of manufacture and
prescription in 1972
A Bit of Data
Source: SAMHSA, 2014
How Common is Opioid
Dependence?
Approximately 2.5 million Americans were
dependent on prescription opioid
prescription pain killers or heroin in 2012.
Source: HHS, 2013
WASHINGTON — Heroin and other
opiate addiction is now claiming more
lives in many communities than violent
crime and car crashes, say America's
top law enforcement officials who
gathered here Wednesday to discuss the
increasing devastation caused by the
drug.
"It's penetrating our entire society,''
Taunton Police Chief Edward Walsh
said. "It's everywhere in our
community.''
Recent Opioid News
• More than 75% of high school heroin users
started with Rx opioids
• Rx opioids and heroin deaths reached an all
time high in 2014; Rx up 16% in one year and
heroin reached 10,574 up 28% from 2013
• Many of the deaths involve illicitly-made
fentanyl and tramadol
• Kratom use is on the rise
Source: CDC, 2015
Prevalence
Cocaine use has gone down in the last few years;
from 2007 to 2012.
• The number of current users aged 12 or older
dropped from 2.1 million to 1.7 million.
• Methamphetamine use has remained steady,
from 530,000 current users in 2007 to 440,000
in 2012.
Client Flow
• Individual makes contact with agency and
undergoes initial screening.
• Individual is determined to fit Block Grant
requirements:
– If they are calling in they will be provided with the
intake information.
– If they are face to face, they will be seen by a
clinician or an appointment will be made.
Client Flow
• Individual completes a bio psychosocial
assessment which addresses all their needs
including co-occurring issues.
• Determination will be made for the appropriate
treatment modality and an individualized
treatment plan will be created with the
individual.
Genetics
Biological
The processes that
initiate and
maintain
alcoholism are
regulated by
interactions among
nerve cells in the
brain.
Psychological
Socio-cultural
Influences susceptibility to
drug usage
Environmental
Data Supporting Genetic
Influences
•
•
•
4 times increased risk in primary
relatives
Monozygotic (MZ)/Dizygotic (DZ)
concordance = 60%/39%
Adopted away children 4 times increased
risk
Genetic Factors
• Cocaine dependence: high degree of heritable
vulnerability but specific genes have not been
identified.
• Methamphetamine Use Disorder: complex and
likely polygenic.
The Reward
Pathway of
Addiction
The limbic system, which
contains the brain’s
reward circuit. It links
together a number of brain
structures that control and
regulate our ability to feel
pleasure. Feeling pleasure
motivates us to repeat
behaviors that are critical
to our existence.
The limbic system is activated
by healthy, life-sustaining
activities such as eating and
socializing—but it is also
activated by drugs of abuse. In
addition, the limbic system is
responsible for our perception
of other emotions, both
positive and negative, which
explains the mood-altering
properties of many drugs.
Brain Reward:
Ventral Tegmental Area (VTA)
• Location of dopamine
cell bodies
• Projects to nucleus
accumbens (reward
center) and prefrontal
cortex (executive
control)
Brain Reward:
Nucleus Accumbens (NA)
• The “reward center” of
the brain.
• Integrates VTA
(dopamine) and PFC
(glutamine) inputs to
determine motivational
output.
– Incentive (appetitive)
– Reward (consummatory)
Brain Reward:
Prefrontal Cortex (PFC)
• Exerts executive control
over midbrain structures
• “Conscience”
• “Mind”
Dopamine Pathways
Serotonin Pathways
striatum
frontal
cortex
hippocampus
substantia
nigra/VTA
nucleus
accumbens
Functions
• reward (motivation)
• pleasure, euphoria
• motor function
(fine tuning)
• compulsion
• preservation
raphe
Functions
• mood
• memory
processing
• sleep
• cognition
VTA
Amphetamines
Opiates
THC
PCP
Ketamine
Nicotine
Nucleus
accumbens
Alcohol
benzodiazepin
es barbiturates
Dopamine Pathways
Most
Rapid in & slow out
(Valium, Buprenex, morphine)
Amount in brain
Slow in & slow out
(Methadone, Klonopin)
Rapid in & rapid out
(Fentanyl, Xanax, Crack)
Least
Time
Pharmacology and
Opioid-Related
Disorders
Opioid Pharmacology
• Types of opioid receptors:
Mu
Kappa
Delta
• Addictive effects occur through activation of
mu.
• Role of kappa and delta receptors in the
addictive process are not well defined
Mu Receptor Drugs
Morphine
Methadone
Hydromorphone
Codeine
Fentanyl
Heroin
LAAM (l-alpha acetyl
methadol)
Buprenorphine
Oxycodone
Hydrocodone
Function of a Full Mu Agonist
Activates the mu receptor
• Highly reinforcing
• Most abused
• Includes heroin, methadone, oxycodone, others
Function of a Partial Mu Agonist
•
•
•
•
Activates the receptor at lower levels
Is relatively less reinforcing
Is less abused
Buprenorphine
Function of a Mu Antagonist
•
•
•
•
Occupies without activating
Is not reinforcing
Blocks and will displace agonist opioid types
Includes naloxone and naltrexone (Vivitrol)
Source: NIDA, 2007
Pharmacology
• First pass after oral ingestion varies: morphine only
15% orally available but methadone is 80-90%
• Duration of analgesia 3-6 hours but constipation or
respiratory depression may last longer as methadone
• Metabolized by liver (glucuronidation or P450 CYP
2D6, 2B6, 3A4
• Opioids are excreted in urine and bile
• Impaired hepatic function could increase concentrations
of opioids and impaired renal function could cause
accumulation of metabolites
Opioid Intoxication
A. Recent use
B. Clinically significant problematic behavioral
or psychological changes…….
C. Pupillary constriction or dilation (anoxia) and
1 or more of the following: drowsiness or
coma, slurred speech and or impairment in
attention or memory
Specify if with perceptual disturbances
Locus Coeruleus
Opioid Withdrawal
A. Cessation/reduction is used or administration
of an antagonist
B. 3 or more of the following: dysphoric mood N/V- muscle aches - lacrimation or rhinorrhea
- pupillary dilation, piloerection, or sweating diarrhea -yawning - fever - insomnia
Why Co-Occurring Diagnosis?
Because of an overlap, drugs of abuse
can cause symptoms that mimic
most forms of mental illness
Which Develops First
Substance Abuse or Psychiatric Illness?
It DepenDs….
Dual Diagnosis Epidemiology
 29%
of Psychiatric Patients
 38% of Chemical Dependency Patients
…have Co-morbid Disorder (dually diagnosed)
Protracted Withdrawal
OPIOIDS
• Intoxication (use): depressant effect, many
reports of stimulant effects at lower doses
• Withdrawal:
Acute: previous slide, remember half-life
determines length of time
Chronic: depression, irritability, anxiety,
insomnia
Major Acute Actions of Cocaine
• Local anesthetic: blocks membrane sodium
channels
• Stimulates CNS: blocks presynaptic
neurotransmitter reuptake pumps (transporters)
– dopamine, norepinephrine and serotonin
• Stimulates sympathetic nervous system
• Chronic effects: neurotransmitter depletion,
receptor upregulation
Cocaine Pharmacokinetics
• Metabolism: primarily by esterases; principal
metabolite benzoylecognine (BE)
• T1/2: 40-90 minutes
• Excretion: urine as BE. Maybe detected 24-72
hours.
• Cocaine + heavy alcohol=cocaethylene
• Longer T1/2 with more severe toxicity, greater
than additive effects on heart rate and violence
potential
Methamphetamine Pharmacokinetics
• MA is an indirect catecholamine and 5-HT agonist
• MA releases newly synthesized (versus stored) DA,
NE, and 5-HT. Enters neuronal membranes through
membrane transporters and storage vesicles via vesicle
transporters
• Decreases DA stores, uptake sites, transporters, tyrosine
hydroxylase and tryptophan hydroxylase activity
• T1/2: 11-12 hrs
• Metabolizes to amphetamine with duration of effect 1012 hrs (versus 30-50 min. for cocaine)
Amphetamine
Cocaine
Routes of Administration
• Intranasal: powder cocaine HCl or MA water
soluble
• Injection: powder cocaine HCl or MA
• Smoked: very rapid onset of action (seconds);
crack (alkaloid cocaine), “ice” – pure crystal
meth
Medical Uses of Stimulants
• Cocaine: topical and local anesthetic
• Other stimulants: Schedule II
 ADHD
 Narcolepsy
 Weight loss
 Decongestant
 Bronchodilation
 Depression
 Reduce fatigue and drowsiness
Stimulant-Related Disorder
Attached to severity add:
• Amphetamine-type substance
• Cocaine
• Other or unspecified stimulant
Stimulant Intoxication
A. Recent use
B. Clinically significant behavioral or psychological
changes
C. 2 or more of the following: tachycardia or
bradycardia- pupillary dilation- increase or
decrease B/P- perspiration or chills- N/V- weight
loss, psychomotor agitation/retardation-muscular
weakness, respiratory depression, chest pain or
cardiac arrhythmia-confusion, seizures,
dyskinesias, dystonias or coma
Specify the specific intoxicant
Specify if with perceptual disturbances
Relative weighting:
+
=
Mild
++ =
Moderate
+++ =
Marked
?
=
Insufficient research
/
=
Common/Rare
Mental Status Findings for ACUTE
COCAINE/STIMULANT INTOXICATION
Cocaine/Amphetamine
“Abnormal” overall behavior
and appearance
+
Disoriented to person, place, date
or situation
none
Dysfunctional immediate, recent,
remote memory
+
Inappropriate degree and direction
of affect
++
Altered mood: depressed
+/+++
Slide 1 of 3
Cocaine/Amphetamine
Altered mood: Overly elated
+++
Confused, disorganized
++
Hallucinations
+++
Delusions
none / +++
Bizarre Behavior
++
Suicidal or danger to self
+++
Homicidal or danger to others
+++
Poor judgment
++
Slide 2 of 3
Stimulant Withdrawal
Dysphoric mood + 2 or more of the following:
1. Fatigue
2. Vivid/unpleasant dreams
3. Insomnia/hypersomnia
4. Increased appetite
5. Psychomotor retardation/agitation
Specify the specific substance
Protracted Withdrawal
Phase
Time Course
Symptoms
Middle crash
starts 1-4 hours
after binge
craving replaced
by desire for
sleep despite
insomnia
Obtain history
of other drug
use and prior
psychiatric
disorders
Late crash
lasts 3-4 days
Hypersomnia
Delay clinical
evaluation until
after
hypersomnia/
crash
increased appetite
Treatment
Slide 2 of 5
Phase
Time Course
Withdrawal
temporary
normalization
lasts 12 hours to
4 days
Symptoms
normalization
of sleep
Treatment
Evaluate for
other drug use
and premorbid
psycho-pathology
fairly normal mood
(only mild dysphoria)
reduced craving
Slide 3 of 5
Phase
Time Course
Symptoms
Treatment
dysphoria
craving
lasts 6-18 weeks
withdrawal
symptoms
emerge--group
support meeting
depression,
lethargy
anhedonia,
anxiety
Initiate O/P
program (e.g.,
individual psychotherapy, education
urine monitoring,
steps to avoid
drug-taking
situations,
behavioral
reemergence of
craving
retraining, cue
extinction, etc.
Slide 4 of 5
Phase
Extinction
Time Course
Symptoms
Treatment
lasts months to
years
gradual return
of mood,
interest in
environment,
and ability to
experience
pleasure
Maintain
abstinence with
relapse prevention
techniques and
long-term selfhelp groups
(such as Twelve
Steps)
gradual extinction
of periodic craving
episodes
Slide 5 of 5
Anyone can be an
addict---it
happens even in
our own
backyard….
Methamphetamine
Medical Morbidities
Psychiatric Morbidities
 Psychosis: usually transient with symptoms of
delusion and hallucinations (commonly visual and
auditory). Sensitization possible.
 Less common symptoms include disorganized
speech and behavior, emotionally labile state and
irrational hostile behavior.
 Can be associated with social withdrawal and
repetitive stereotyped behaviors.
 Mood disorders: rates of depression and anxiety
disorders substantially higher.
Cocaine and Pregnancy/Fetal
Development
•
•
•
•
•
Irregular placental blood flow
Placental abruption
Premature rupture of membrane
Premature labor and delivery
Possible fetal effects: prematurity, low birth weight,
decreased head circumference, lower developmental
test scores and delayed language skills
There is no strong evidence of its toxic effect on the
developing fetus!
Treatment Modalities
• Treatment modality determined
– Outpatient
– Inpatient
– Mental Health
– Co-Occurring
– MAT
• Methadone
• Vivitrol
• Suboxone
Treatment Practices/Interventions
• Client participates in treatment modality
assigned
– Individual therapy
– Group therapy
– Crisis intervention
– Random urinalysis
– On going treatment planning
– Medication (if appropriate)
Clinical Interventions
• Staff were introduced to Evidence Based Practices (EBP’s)
– Motivation Interviewing (MI)
– Motivational Enhancement Therapy (MET)
– Cognitive Behavioral Therapy (CBT)
– Dialectical Behavioral Therapy (DBT)
– Living in Balance – Life of Recovery (LOR)
– 12 Step Facilitation Therapy (TSF)
– Seeking Safety
– Triple P Parenting
– Solutions to Wellness
– Behavior Modification
– 12 Step Support Groups – MA in house, AA, NA, CR in community
• Staff began to utilize EBP’s in their group and individual sessions
Clinical Services
• Group Counseling
– Life Of Recovery (LOR)
– Building Blocks – Specialty Group for Pregnancy and Post
Partum
– Specialty Groups
• Men's/Women’s Specific
• Parenting
• Seeking Safety
• Grief
• Anger Management
• Continuing in Recovery
– 12 Step Meetings
What is Building Blocks…
• Specialized program for pregnant and post-partum
women in MAT
• Utilizing evidenced-based clinical and educational
information
• Covering conception/pregnancy, delivery and beyond
• Safe haven for group/clinical support
• Community partnership
• Resource development
Community Integration –
Who Collaborated
•
•
•
•
•
•
•
•
•
•
•
•
•
Department of Health – Dieticians & Nutritionist
Woman’s Center of Jacksonville– Domestic Violence
DCF – “Who are we and what can we offer”
Healthy Mothers, Healthy Babies Coalition of N. FL
La Leche
North Florida Child Safety – Wolfson Children’s Hospital
Planned Parenthood
Independent Pharmacist
RN’s and LPN’s
MAT Counselors
CPR Instructor
Adoption Attorney
Working on: Pediatrician and Midwife
Treatment Concerns/Barriers
• Individual is not ready – seeking treatment for
someone else
• No knowledge of services
• Stigma
• Trauma history
• Fear
• Money
• Child care needs
• Transportation
Pharmacologic
Treatment Options
Methadone
• For opioid dependence only.
• It is a highly regulated Schedule II opioid.
• DCF, DEA and Board of Pharmacy perform
regular and stringent audits of Methadone
clinics.
• The gold standard for pregnant women due
to potential fetal demise from withdrawal.
• Stops withdrawal symptoms and craving.
Methadone (cont’d.)
• Most researched medication used in the
treatment of addiction.
• Clients don’t get high once stabilized.
• Tolerance is not as much of a factor with this
medication.
• Do not confuse its abuse with the methadone
prescribed from pain clinics.
Methadone (cont’d.)
Once stable, the majority of clients reveal the
following:
Reduced spread of disease
Stable home life
Reduced crime
Stable finances/job
Reduced relapse rate
Suboxone/Subutex
• Schedule III medication for opioid dependence
only.
• Buprenorphine is the active drug (Subutex) and
attached to naloxone (Suboxone)
• Can only be prescribed by physicians with a
“x” number. Certain training or course is
required.
• For individual physicians, limited to 100 active
clients.
Suboxone/Subutex (cont’d.)
• Given sublingual. Takes approx. 10 minutes to
dissolve.
• A partial mu agonist with reduced abuse
potential. Long duration of action. Holds tight
to the mu receptor.
• Clients rarely need more than 16mg, though
max dose is 32 mg.
• Must be in withdrawal before the induction
process is started.
Suboxone/Subutex (cont’d.)
• Clients don’t get high once stable.
• Can be used in pregnancy.
• Clients also reveal the same as Methadone once
stable:
Reduced spread of disease
Stable home life
Reduced crime
Stable finances/job
Reduced relapse rate
Vivitrol
• For opioid and alcohol dependence.
• Injectable form of Naltrexone; a full mu
receptor antagonist. It fully covers the receptor
and does not allow opioids to attach.
• This is not an opioid. Not mood altering and
not addictive.
Vivitrol (cont’d.)
• A monthly injection. The pill form can be
taken every day but compliance is a problem
and side effects are a greater possibility.
• Blocks action of opioids and reduces cravings
for opioids.
• Reduces craving for alcohol and reduces
effect.
Naloxone
• An opioid antagonist that has, until recently,
only been available IV and used for overdose
on opioids
• Recently, a SC/IM form has been approved for
caregivers – Evzio
• An even newer intranasal version gained FDA
panel approval
Treatment for Psycho-Stimulants
• Pharmacologic: Symptomatic only.
Depression, anxiety and psychosis. Supportive
for physical symptoms.
• Non-pharmacologic: Psychosocial treatments.
Reason for Hope
Dopamine Density
Questions?
Sources
Centers for Disease Control (2011). Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999 – 2008.
Morbidity and Mortality Weekly Report 2011: 60(43); 1487-1492.
Centers for Disease Control (2015). Increases in Drug and Opioid Overdose Deaths – US 2000-2014. Morbidity & Mortality Weekly
Report 2015.
Centers for Disease Control and Prevention (2015). National Vital Statistics System mortality data. Available from
URL:http://www.cdc.gov/nchs/deaths.htm.
National Institute on Drug Abuse 2007. The Neurobiology of Drug Addiction. Retrieved from
http://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/section-iii-action-heroin-morphine/4-opiatesbinding-to-opiate-rece
Substance Abuse and Mental Health Services Administration (2014). Results from the 2013 National Survey on Drug Use and
Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD.
Substance Abuse and Mental Health Services Administration (2013). Results from the 2013 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 (2012). Results from the 2013 National Survey on Drug Use and
Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD.
US Department of Health and Human Services (HHS), 2013. Addressing Prescription Drug Abuse in the United States. Washington,
D.C.