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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.