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 Commons !

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 !ast 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

Source: Substance Abuse and Mental Health Services Administration. (2009). Results From the 2008 National Survey on Drug Use and Health: National Findings Rockville, Maryland.

Past-Year Initiates for Specific Illicit Drugs Among Persons Age 12 or Older, 2008

Overview of Substance and Drug Use

Overdose Deaths in Pennsylvania

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

DRUG OVERDOSE DEATHS IN PENNSYLVANIA

Year Number of

Deaths PA

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

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

•! 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. Of these, 490 (17%) were heroin only, while 2,439 (83%) involved multiple

drugs.

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Why Drug Misuse Occurs

–! 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 Angie Garrett from Ridgely, USA [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

By MartijnL (Own work) [CC-BY-SA-3.0-nl (http://creativecommons.org/licenses/by-sa/3.0/nl/deed.en)], 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

Initiation •!Escape-avoidance •!Appropriate

Prescription Use

Continuation •!Loss of problem-

solving capacity

Maintenance •!Rationalization

•!Projection

Dependence •!Use to avoid

negative physical and psychological consequences

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

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

•! Aggressively complaining about need for medication

•! Asking for specific medicine by name

•! Asking for non-generic medication

•! Requesting to have dosage increased

•! Taking a few extra, unauthorized doses on occasion

•! Claiming multiple pain medication allergies

•! Visiting multiple docs for controlled Rx

•! Hoarding medication

•! Frequent calls to clinic

•! Using controlled substance for non-pain relief purposes (e.g. to enhance mood, sleep)

Less 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 non-pharmacologic treatments

•! Frequent unauthorized dose escalation after being told this is inappropriate

•! 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

More Serious Most Serious

Continuum of Aberrant Prescription Drug Misuse (cont’d)

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