Addiction update emerging trends and medication options
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Addiction Update: Emerging Trends and Medication Options. Ernest rasyidi , m.d. Alcohol Use in the U.S. Estimated 133.4 million current drinkers in 2011 About 58.3 million people Binge Drank in past 30 days About 15.9 million people were heavy drinkers

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Addiction Update: Emerging Trends and Medication Options

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Addiction update emerging trends and medication options

Addiction Update: Emerging Trends and Medication Options

Ernest rasyidi, m.d.


Alcohol use in the u s

Alcohol Use in the U.S.

Estimated 133.4 million current drinkers in 2011

About 58.3 million people Binge Drank in past 30 days

About 15.9 million people were heavy drinkers

About 9.7 million persons aged 12 to 20 (25.1 percent of this age group) reported drinking alcohol in the past month

Among the under aged, about 6.1 million were binge drinkers, and 1.7 million were heavy drinkers


Alcohol use rates

Alcohol Use Rates


Alcohol use definitions

Alcohol Use: Definitions

Current (past month) use - At least one drink in the past 30 days.

Binge use - Five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past 30 days.

Heavy use - Five or more drinks on the same occasion on each of 5 or more days in the past 30 day


Alcohol use ages 12 20

Alcohol Use Ages 12-20


Alcohol

Alcohol


Alcohol cont

Alcohol Cont…

A “forty” = 40 oz beer ~ 3+ drinks, malt liquor stronger, “40” ~ 4.5 drinks

“Tall boy” = 24 oz = 2 drinks

Standard wine bottle = 750mL = 5 drinks

Pint of liquor = 11 drinks

A “fifth” = 750mL = 17 drinks

A “Handle” = 1.75L = 39 drinks

This assumes 80 proof (40% alcohol) liquor, some are stronger


Naltrexone revia vivitrol alcohol

Naltrexone (Revia, Vivitrol): Alcohol

Opiate receptor blocker

Shown to reduce cravings

Decreases frequency of use

Decreases intensity of usage

Main side effects: nausea, dysphoria, headache, fatigue


Naltrexone alcohol

Naltrexone: Alcohol

  • Available Forms:

    • Daily pill

    • Monthly injection

    • Implant (coming soon?): Placed under the skin and replaced quarterly. Used in Australia off label, not approved in US


Disulfiram antabuse

Disulfiram (Antabuse)

Blocks acetylaldehyde dehydrogenase, and enzyme necessary to break down alcohol

Causes acetylaldehyde to build up leading to “Disulfiram Reaction”

Flushing, Nausea, Vomit, Headache, Racing Heart Beat, Dizziness

Taken orally, at least daily to be effective

Rare cases of lethal reaction when taken with alcohol (due to irregular heartbeat)


Gabapentin neurontin

Gabapentin (Neurontin)

Off label – Non FDA approved

Anti-seizure medication

Non-addictive

Helps with anxiety related to Alcohol Withdrawal

Wide dosing range (100mg-3600mg/day)

Main side effects include drowsiness and dizziness


Topiramate topamax

Topiramate (Topamax)

Off label – Non FDA approved

Anti-seizure medication

Non-addictive

Helps with impulsivity often seen in binge drinking

Patients describe feeling like things are slowed down so they can think things through

Main side effects: Cognitive slowing (“Dopamax”) and weight loss


Tobacco use 68 2 million users

Tobacco Use: 68.2 Million Users


Smoking cessation options

Smoking Cessation Options

Nicotine replacement: Patch, Lozenge, Gum, Inhaler

Bupropion

Varenicline: Beware vivid dreams and rare SI

E-cigs?


Electronic cigarrettes

Electronic Cigarrettes


Electronic cigarette structure

Electronic Cigarette Structure


Rates of drug use ages 12 and older

Rates of Drug Use: Ages 12 and Older

NSDUH 2011


Rates of drug use

Rates of Drug Use

8.9% of Americans age 12 or older are “current” (used in the past month) users of any illicit drug

22.0% of full time college students age 18-22 are current users, comparable to their age matched peers (23.5%)


Cannabis

Cannabis

Most widely used illicit drug

Can be smoked, eaten, or in some rare cases liquid form

Varies widely in cost and potency, but in general, most cannabis available currently is far more potent than cannabis consumed in 1960-70’s (4-5% THC vs 12-18% THC)


Cannabis 101

Cannabis 101

Infinite number of nicknames based on region and strain of plant being referred to. Most common generic terms include “weed” and “pot”

Most strains are variations of Cannabis Indica, Cannabis Sativa, or some hybrid

Indica ~ “body high” relaxing, sedating

Sativa ~ “head high” psychedelic, mind altering

THC = main psychotropically active ingredient, most concentrated in plant resin


Whole plant

Whole Plant


Cannabis bud

Cannabis Bud


Thc concentrated resin

THC concentrated resin


Cannabis smoked

Cannabis Smoked

Joints – Cannabis cigarettes

Blunts – Hollowed out cheap cigars filled with Cannabis and re-wrapped

Bowls – Cannabis packed into the bowl of a pipe

Bong – Pipe with water filter element

Vaporizer – Heats Cannabis so that THC evaporates and can be inhaled without burning plant material


Joints vs blunts

Joints vs Blunts


Paraphernalia

Paraphernalia


Edibles

Edibles


Units of measurement

Units of Measurement

“Dime bag” = $10 worth

“Dub” = $20 worth

A gram

“eighth” = 1/8 oz = 3.5 grams = $40-60 for fairly high potency


An eighth

An Eighth


Addiction update emerging trends and medication options

Wax

AKA Butane Hash Oil (BHO)

Highly concentrated resin produced using a solvent, such as butane

Production process can be dangerous as solvent are highly volatile, can lead to fires/explosions

Sometimes can be mistaken for meth lab explosion


Addiction update emerging trends and medication options

Wax


Rx meds

Rx Meds

Benzos, downers, anxiety meds, sleep meds: Klonopin, Xanax, Valium, Ativan, Ambien

Stimulants: Ritalin, Adderall

Muscle Relaxers: Soma

Rx opiates: Vicodin, Percocet (Percs), Oxycodone/contin (Oxy), Roxicodone (Roxy), morphine, dilaudid, methadone

Rx opiates far more common than heroin

Ask about crushing/snorting


Opiates naltrexone

Opiates: Naltrexone

Blocks the “High” from opiates

Reduces cravings

Can precipitate withdrawals if Patient has opiates in their system


Opiates methadone

Opiates: Methadone

Pure opiate

Long acting, decreases cravings, should block the high from other opiates

Can overdose

Technically, should be administered in a highly structured setting (methadone clinic) with strict requirements. Fairly demanding but does provide structure and accountability


Opiates buprenorphine suboxone

Opiates: Buprenorphine (Suboxone)

Partial opiate agonist, binds very tightly, long acting

Theoretically, should give enough activation to prevent cravings, not enough to get high.

Because it binds so tightly to receptors, will prevent other opiates from having effect

Will cause withdrawal if Patient has opiates in their body

Warn patients about emergency procedures


Opiates buprenorphine suboxone1

Opiates: Buprenorphine (Suboxone)

  • Availability…

    • Tab (getting phased out)

    • Gel film

    • Implant good for 6 months (in testing)


Reformulated tablets resistant to crushing

Reformulated Tablets Resistant to Crushing

Multiple strikes with a hammer deforms but does not crush reformulated tablets into powder

From the Presentation To Joint Meeting of the Anesthetic and Life Support Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee, May 5 2008


Crushing between spoons

Crushing Between Spoons

Reformulation (left) cannot be crushed between spoons

Original formulation (right) can be crushed between spoons

From the Presentation To Joint Meeting of the Anesthetic and Life Support Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee, May 5 2008


Manual crushing followed by dissolution

Manual Crushing Followed by Dissolution

From the Presentation To Joint Meeting of the Anesthetic and Life Support Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee, May 5 2008


Tampering for iv abuse

Tampering for IV Abuse

New formulation results in gelatinous material which cannot be drawn into a syringe for injection (the syringe is empty)

From the Presentation To Joint Meeting of the Anesthetic and Life Support Drugs Advisory Committee and Drug Safety and Risk Management Advisory Committee, May 5 2008


Vignette 1 par

Vignette #1 PAR


Vignette 2 par

Vignette #2 PAR


Cures implications for treatment

CURES: Implications for Treatment

PAR is not a substitute for drug testing, collateral info, or clinical judgment

PAR should not be used to catch patients in a “gotcha” scenario. Patients with addiction often have severe guilt and shame associated with their use and treatment interventions should work to break these barriers down instead of re-enforcing them


Cures implications for treatment1

CURES: Implications for Treatment

PAR should be discussed at outset and is an important part of the structure/frame of treatment and results should be discussed

PAR should promote safety by helping to reduce risk of overdose and drug interactions

PAR should be used to help determine clinical decisions regarding level of care, frequency of monitoring, as well as risk/benefit of particular interventions


Cures limitations

CURES Limitations

  • Be aware of possible false negatives!

  • Pharmacy participation is supposed to be mandatory and prescriptions should be reported within a week of dispensing. Even so, be aware that not all Rx’s will show up

  • Keep in mind that Veterans’ Administration Rx’s do not show up

  • Out of state Rx’s will not show up

  • No entries will show up if patient is using aliases or if they are diverting from friends/street


Heroin balloons

Heroin Balloons


Cocaine and crack

Cocaine and Crack


Crystal meth

Crystal Meth


Stimulants

Stimulants

  • No FDA approved treatments (all off-label use)

    • Bupropion (Wellbutrin): Antidepressant, works on similar chemicals to cocaine/amphetamine but in a different way

    • Concerta: Long acting form of Ritalin, currently undergoing trial, results look promising but raises concerns for abuse similar to opiate replacement therapy

    • Vaccines: In development for decades. Patients given an injection which stimulate immune response in body. Prevents cocaine from entering the brain, eliminates High. Does not protect from Overdose. Needs “booster” shots every few months. Raises legal/ethical concerns. (Parents wanting for kids “preventatively,” involuntary treatment, etc…)


Hallucinogenics

Hallucinogenics

LSD: paper tabs, ingested, rarely gelatin film. Difficult to obtain true LSD since 2000

Ecstasy, XTC, MDMA: tabs, often impure, typically mixed with amphetamines

Hallucinogenic Mushrooms, ‘Shrooms, Psilocybin

Peyote/Mescaline: Legitimate access restricted to certain Native American tribes, difficult to obtain

Ayahuasca: Amazon jungle, holy sacrament for indigenous church


Synthetic hallucinogens

Synthetic Hallucinogens


Natural hallucinogens

Natural Hallucinogens


Emerging drugs

Emerging Drugs

Spice: Synthetic Cannabinoid laced on neutral plant. Touted as being able to pass drug tests. Much more psychotogenic given potency. (Illegal)

Bath Salts, MCAT: Similar to Amphetamines, smoked, snorted, injected, not detected on most drug tests. (Illegal-ish)

Salvia: Plant based cousin of Cannabis, produces much more powerful dissociative effects. (Legal except for minors)


Emerging drug use

Emerging Drug Use

Use of Synthetic Marijuana held level among 12thgraders in 2012 —the second year of measurement—at 11.3% annual prevalence (4th most common behind Alcohol, Tobacco, and Marijuana)

The annual prevalence rates for bath salts were 0.8%, 0.6%, and 1.3% for grades 8, 10, and 12, respectively

The annual prevalence rates in 2012 for salvia are 1.4%, 2.5%, and 4.4% in grades 8, 10, and 12

MTF 2012


Emerging drugs1

Emerging Drugs


Emerging drugs2

Emerging Drugs

Kratom: Plant leaves from South East Asia, consumed as a powder in capsules or made into tea. Works on opiate system.

Methoxetamine: Synthetic powder that acts like ketamine. Snorted, taken sublingually, or sometimes injected into muscle


Emerging drugs3

Emerging Drugs


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