Addiction Part 1

1. Addiction Part 1 Understanding the SUD continuum Alëna A. Balasanova, MD, FAPA April 5, 2019

2. Disclosures • I have no relevant financial relationships with commercial interests. • I have no actual or potential conflicts of interest in relation to this presentation

3. Objectives • Define addiction and substance use disorder and review related terminology • Outline the DSM-5 criteria for substance use disorder

4. First things first: what is addiction? • A chronic brain disease that has the potential for both recurrence (relapse) and recovery (remission) • Associated with uncontrolled or compulsive use of one or more substances • The most severe form of Substance Use Disorder (SUD)

5. Uncontrolled use despite negative consequences

6. Okay, so what then is SUD? • A medical illness caused by repeated misuse of a substance or substances • Develops graduallyover time • Leads to brain changes

7. …and what is substance misuse? The use of any substance in a way that can cause harm to the individual or those around them

8. SUD-related brain changes result in impaired executive function This causes problems with self-control and decision-making

9. Continuum

10. Addiction: what is it not? • Moral failing • Character deficit • Bad behavior • Poor decision-making • Voluntary choice Society has judged substance use throughout time Historic love-hate relationship with “booze” & “dope”

11. The Language ofAddiction

12. Language can help de-stigmatize

13. The words we choose matter NOT THAT Substance Abuse Replacement therapy Alcoholic Drug Abuser Addict SAY THIS Substance Use Disorder Substance Misuse Substance Use Addiction Patient with a SUD  Commonly used terms explicitly and implicitly convey that patients are at fault for their disease and influence perceptions and judgments

14. What we don’t think we think • Impact of bias is universal; it holds true even for highly-trained and experienced health professionals

15. Implicit bias in clinical practice 2016 study of ~300 MDs at an Ivy League Boston hospital, looking at attitudes and clinical practices • 38% felt that SUD is different from other chronic diseases because people who use drugs or alcohol are “making a choice” • 14% felt that medication treatment using opioid-agonists is “simply replacing one addiction for another” • 12% thought someone “using drugs is committing a crime and deserves to be punished”

16. Language impacts patient care Psychiatric practitioners were found to be more likely to assign blame, agree with need for punitive action and find a “substance abuser” less deserving of treatment than if same person was described as a “patient with a SUD”

17. Bias impacts clinicians also Health professionals generally hold negative attitudes toward patients with SUDs. Such attitudes are linked to lower levels of clinician empathy and engagement  burnout for clinician, poorer outcomes for patient

18. The costs of our attitudes? The costs of our attitudes…? https://pbs.twimg.com/media/Cz0_XHcWIAAaUVq.jpg

19. Scope of the problem

20. How common are SUDs?

21. Screening for substance use

22. Screening for substance use

23. Diagnosing SUD

24. Substance-Related and Addictive Disorders Categories of symptoms to make a diagnosis of SUD 1. Impaired Control 2. Social Impairment 3. Risky Use 4. Pharmacological Criteria

25. Impaired Control • Taking the substance in larger amounts or over a longer period than was originally intended • Having a persistent desire to cut down or regulate substance use but reporting multiple unsuccessful efforts to do so • Spending a great deal of time obtaining, using, or recovering from effects of the substance • Craving, as manifested by an intense desire or urge for the drug that may occur at any time (but is more likely when in an environment where the drug was previously obtained or used)

26. Social Impairment • Recurrent substance use results in failure to fulfill major obligations at work, school, or home • Continued substance use despite social or interpersonal problems caused or exacerbated by the effects of the substance • Important social, occupational, or recreational activities are given up or reduced because of substance use

27. Risky Use • Recurrent substance use in situations in which it is physically hazardous • Continued substance use despite knowledge of having a physical or psychological problem that is likely to have been caused or exacerbated by the substance

28. Pharmacological Criteria • Tolerance, signaled by increasing doses of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed • Withdrawal symptoms occurring with abrupt reduction or cessation of substance use in an individual with previous prolonged use of the substance **Pharmacological criteria alone is insufficient for diagnosis of SUD if occurring during the course of appropriate medical treatment

29. Specifiers There are 11 total criteria for SUD consisting of the 4 categories of symptoms. To specify severity of SUD, count up the criteria met: Mild: 2-3 Moderate: 4-5 Severe: 6+

30. Summary: Diagnosing SUD

31. Take-home points • Addiction is chronic, relapsing medical illness • The language that we use to describe addiction and patients with SUDs can help de-stigmatize these conditions • It doesn’t take much (2 symptoms) to meet criteria for a diagnosis of SUD using DSM-5

32. References Botticelli MP, Koh HK. Changing the language of addiction. JAMA. 2016;316(13):1361-1362 Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/data/ Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: Results from the National Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999–2015. NCHS data brief, no 273. Hyattsville, MD: National Center for Health Statistics. 2017. Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757-766 Grant BF, Saha TD, Ruan WJ, et al. Epidemiology of DSM-5 Drug Use Disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2016;73(1):39-47. McLellan AT, Lewis DC, O’Brien CP et al. Drug Dependence: a Chronic Medical Illness. JAMA 200;284(13):1689-1695. Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452. DOI: http://dx.doi.org/10.15585/mmwr.mm655051e1 U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016. Van Boekel LC, Brouwers EP, van Weeghel J, et al. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013 Jul 1;131(1-2):23-35. WakemanSE, Pham-Kanter G, Donelan K. Attitudes, practices and preparedness to care for patients with substance use disorder: Results form a survey of general internists. Substance Abuse. 2016;47(4):635-641

33. Working with communities to address the opioid crisis. • SAMHSA’s State Targeted Response Technical Assistance (STR-TA) Consortium assists STR grantees and other organizations, by providing the resources and technical assistance needed to address the opioid crisis. • Technical assistance is available to support the evidence-based prevention, treatment, and recovery of opioid use disorders. Funding for this initiative was made possible (in part) by grant no. 6H79TI080816 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

34. Working with communities to address the opioid crisis. • The STR-TA Consortium provides local, experienced consultants to communities and organizations to help address the opioid public health crisis. • The STR-TA Consortium accepts requests for education and training resources. • Each state/territory has a designated team, led by a regional Technology Transfer Specialist (TTS) who is an expert in implementing evidence-based practices. Funding for this initiative was made possible (in part) by grant no. 6H79TI080816 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

35. Contact the STR-TA Consortium • To ask questions or submit a technical assistance request: • Visit www.opioidresponsenetwork.org • Email str-ta@aaap.org • Call 401-270-5900 Funding for this initiative was made possible (in part) by grant no. 6H79TI080816 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.