A BioPsychoSocial Update of Substance Use Disorders

1. A BioPsychoSocial Update ofSubstance Use Disorders George Kolodner, M.D. Kolmac Clinic gkolodner@kolmac.com DC EAPA July 19, 2012

2. Substance Use by Kolmac Patients

3. High School Drug Use Patterns(www.monitoringthefuture.org) • Utilization is stable for overall drug use • Dramatic increase in prescription opioids • Increase in marijuana • Decrease in cocaine and methamphetamine

4. “Rise in Pill Abuse Forces New Look at U.S. Drug Fight” NY Times, July 17 • Overdose deaths • 20,000 from prescription drugs • 16,000 from illicit drugs • Shifting the policy focus from cocaine and heroin to prescription drugs • Mexico: shifting from reducing drugs to reducing violence and corruption • Reduction in cocaine use (5.8  1.5 million) • Due to success of interdiction or decreased demand?

5. BioPsychoSocial: 3 Inter-related Aspects of Person and Disease • Biological: substance + person’s physiology • Sedative vs. stimulant, purity, route of administration • High tolerance, opioid receptor sensitivity, dopamine receptor level, ADHD • Two types of drug addiction damages • Hijackers: Mega doses of internal chemical • Opioids, nicotine, cannabis • Smashers: External impact on multiple sites • Alcohol, cocaine and other stimulants

6. BioPsychoSocial: 3 Inter-related Aspects of Person and Disease • Psychological • Expectation and setting • Personality (who has the disease) • Other psychiatric disorders • Social • Legal vs. illegal • Legality and regulations constantly changing • Availability and customs

7. Drug Control vs. Drug Treatment • Drug Control (“Supply Side”) 60% funding • What substances should be legal and how should they be regulated? • What are the most effective social responses to people who use illegal drugs or do not abide by the regulations for legal substances? • Drug Treatment (“Demand Side”) 40% funding • What are the bio-psychological effects of psychoactive substances? • What is the most effective treatment approach for people who develop substance use disorders?

8. Drug Control Issues Prohibiting a substance for which there is a demand creates a pseudo-monopoly for criminals

9. Prices of Illegal Drugs • Cocaine: retail price of one gram in 2011: $177 • 74% cheaper than 1981 • 16% cheaper than 2001 • Heroin and methamphetamine: similar reductions • Marijuana: no significant price reduction NY Times, 7/12

10. Cost and Use of Legal Drugs • Alcohol • Raising the price of alcohol by increasing excise tax reduces heavy and binge drinking without affecting light to moderate use • Paying The Tab, Philip Cook. 2007 • Tobacco • Increasing the price of cigarettes reduces use, particularly by youth • Increased use of lower taxed mini-cigars by youth

11. Social Issues • Drug violation arrests: 1.64 million in 2010 • 80% of possession, half for small amounts of marijuana • NYC, 2011: 85,000 drug misdemeanor arrests at $1,500 to $2,000 each • Imprisonment for drug offenses • 50% of federal prisoners • 20% of state prisoners • Reduced public concern about drug abuse (Gallup poll)

12. Pain Pill “Epidemic” How Did We Get Here?

13. Brief History of Pain Pills: #1 • Apprehension of physicians to medicate pain dates back to 1914 Harrison Narcotic Act • Criminalized opioid dependency • Both addicts and treating physicians were jailed • It is still illegal for physicians to prescribe opioids to an opioid addict for addiction • Blurred line between treating pain or treating addiction

14. History #2, 1990’s: Concern About Under Medicating of Pain • Pressures on physicians to be more aggressive • 1999: Pain as the “Fifth Vital Sign” promoted by Veterans Administration, Joint Commission, and State of California • Reassurances from pain management specialists about addictive potential of opioid pain medications

15. History #3, 1996: “Oxycontin” • Long acting formulation of oxycodone • Oxycodone introduced in 1917 because of concern about addictive properties of heroin, which had been introduced in 1898 because of addictive properties of morphine • Promoted by Purdue-Pharma for its safety • Fines for misrepresentation, other suits pending • Capsule altered for snorting and injection • Spread opioid addiction to rural America (“hillbilly heroin”)

16. History #4: Pain Mills” • Physicians established high volume practices that dispensed pain pills for cash • Wide variation in regulation by states • Broward County, Florida became infamous • DEA enforcement influenced by “pain lobby”

17. History #5: Internet Sales • Complex international organizations eluded enforcement efforts • Illustration: Try internet search for “oxycodone no prescription” • Impact limited by expense and unreliability

18. Update on Treatment of Opioid Addiction: Buprenorphine • Improved clinical results when patients stay on buprenorphine longer • Physicians reaching 100 patient limit • Some diversion, especially of “mono” form • But better treatment results for patients who used street buprenorphine • Resistances within the addiction field • Professional: 28 day residential treatment centers • Recovery community: Narcotics Anonymous • Some states do not allow physicians on buprenorphine to return to practice

19. Buprenorphine vs. Methadonein Pregnancy • Same incidence of neonatal abstinence syndrome (NAS) • Less severe NAS with buprenorphine • 89 % less medication • 43% less hospital days • More discontinuation of buprenorphine than methadone because of dissatisfaction with medication

20. What Are We Getting Into? Coming to a Dispensary Near You: “Medical” Marijuana in DC

21. Changes in Marijuana Use • Utilization is up among high school students • 2010: reversal of downward trend • www.monitoringthefuture.org • Purity is up • Based on DEA street buys

22. Possible Changes in Legal Status • Current DEA Controlled Drug Status • Marijuana: Schedule 1 • Synthetic THC (dronabinol, “Marinol”): Schedule 3 • Decriminalize • Manage offenses with fines instead of incarceration • Legalize for recreational use • Regulate and tax like alcohol • Legalize for medical use • Exists in 17 states plus D.C. (First: California, 1996) • Physicians are not the driving force in this effort

23. Arguments For and AgainstMedical Marijuana • FOR: People are suffering from medical conditions that respond to smoked marijuana and no other medication, including dronabinol. • AGAINST: Marijuana is a complex substance taken via a high potency route of administration. It should therefore be subjected to the same quality standards and dosing studies as any other pharmaceutical, dispensed through traditional pharmacies, and regulated by the FDA.

24. DC Medical Marijuana Regulations(Chapter 99: Definitions, pp. 113-114) Qualifying medical condition means: (a) Human immunodeficiency virus; (b) Acquired immune deficiency syndrome; (c) Glaucoma; (d) Conditions characterized by severe and persistent muscle spasm, such as multiple sclerosis; (e) Cancer; or

25. DC Medical Marijuana Regulations **(f) Any other condition, as determined by rulemaking, that is: (1) Chronic or long lasting; (2) Debilitating or interferes with the basic functions of life; and (3) A serious medical condition for which the use of medical marijuana is beneficial: (1) cannot be effectively treated by any ordinary medical or surgical measure; or (2) For which there is scientific evidence that the use of medical marijuana is likely to be significantly less addictive than the ordinary medical treatment for that condition

26. Continued Legal Ambiguities • DOJ Memo, 10/09: Federal government would not act against marijuana in states where its use for medicinal purposes was legal • DOJ Memo, 6/11: “Persons who are in the business of cultivating, selling, or distributing marijuana, and those who knowingly facilitate such activities, are in violation of the Controlled Substances Act, regardless of state law.”

27. Implementation Problems • Qualifying medical conditions • California: “pseudo medicalization” = de facto recreational legalization • Dosing and purity • Relationship with physician • Addressing drugged driving • California: “thug factor”

28. Possible Resolution • Keep specific diagnostic indications • Remove “catch all” category • Allow for exceptions on a case by case basis

29. Marijuana: Negative Effects • Evidence for residual negative impact on executive cognitive functions • Attention, concentration • Ability to plan, organize, solve problems, make decisions • Physical addiction documented • Withdrawal symptoms: • Increased blood pressure • Insomnia • Irritability • Anxiety • DSM-5 has new diagnosis for “Cannabis Withdrawal”

30. Marijuana: Treatment Issues • Marinol for detoxification and maintenance • Initial research studies have not been promising • Difficulty being taken seriously in Narcotics Anonymous • Marijuana Anonymous available • Cultural problems in young adults • Persistent use of alcohol by marijuana addicts • Persistent use of marijuana in other addictions

31. Tobacco The Elephant In The Room: Addressing Tobacco Addiction In Treatment Programs For Substance Use Disorders

32. Annual Mortality • Kills 50% of the people that use it • USA • Nicotine: 440,000 • Alcohol: 100,000 • All other drugs: 36,000 • Worldwide: 4.9 million • Projected by 2020 to kill 10 million people and become the #1 cause of death

33. Secondhand Smoke: Annual Impact • Smoke from burning end of cigarette is more toxic than smoke that is inhaled • 53,000 deaths of non-smokers • Compares with 11,000 deaths from drunk drivers • 35,000 from heart attacks • 3,000 from lung cancer • Young children are especially sensitive • Under 18 months: 300,000 cases of pneumonia and bronchitis • 26,000 develop asthma

34. Correcting Mistaken Beliefs • Lung cancer is not the biggest medical danger • Only 15% of smokers develop lung cancer • Tobacco is the #1 risk factor for heart attacks • Risk is reduced by 50% one year after quitting • Tobacco is leading cause of COPD • Nicotine is addicting but not toxic • No major medical consequences from nicotine except slower wound healing after surgery • Nicotine patch does not slow healing

35. Tobacco Utilization in USA • Reduced in adults • 1964: 40%  Now: 20.6% • Higher in people with substance use disorders • Alcoholics: 34% to 56% • Drugs: 52% to 68% • *Highest in patients in treatment for SUDS • 65% to 85% (especially methadone) • Tobacco shortens life span of recovering alcoholics

36. Paying Lip Service to Addiction:Changing Our Language • Tobacco user  tobacco addict • Smoking cessation  tobacco addiction rehabilitation • Ex-smoker  recovering smoker

37. Similarities to Other Addictions • Continued use despite adverse consequences • Genetically influenced • Rapid metabolizers more susceptible to physical dependence than slow metabolizers • Withdrawal symptoms are acute and protracted • Relapses are common and occur in response to the standard 3 triggers: • Exposure to substance • Cues (conditioned learning associations) • Stress

38. Differences from Other Addictions • Greater certainty of toxic effect but more extended length of time to develop • 12 step support (Nicotine Anonymous) struggles • Greater tolerance of use by recovery community • Research money is managed by National Cancer Institute not National Institute of Drug Abuse • Insurance coverage is very limited

39. Treatment The Easier Way • Adequate nicotine replacement treatment • Ignoring package instructions and media negativity • BG&E • Intensive group based rehabilitation • Use traditional addiction treatment concepts • Continued care group therapy

40. Medication Options • “Nicotine replacement” (detoxification) • Long acting: patch • Short acting • Non-prescription: gum, lozenges • Prescription: nasal spray, “inhaler” • Electronic cigarette: unregulated and not recommended • Wellbutrin/Zyban (buproprion) • Chantix (varenicline): nicotine receptor agonist • Over-reaction about causing depression and heart problems

41. Mayo Clinic Treatment Program • Higher doses of multiple medications for 3 to 6 months or more • Remove withdrawal as an issue • Standard recommendations are inadequate • Fear of nicotine toxicity is misplaced • Use for as long as it takes • “This is not an infectious disease.” • 8 day residential program: 52% 1 year quit rate

42. Tobacco And Traditional Addiction Rehabilitation • New Jersey joins New York in prohibiting tobacco in residential rehabilitation • No integration with Mayo SUDs program • Stones on the windowsill • Eliminating tobacco breaks at Kolmac

43. Integrating Treatment of Tobacco Addiction Into Addiction Programs • Challenging the belief that this will interfere with recovery • Addiction treatment programs as enablers of tobacco addiction • Most users express the desire to quit • How to address this and respect the desire of others not to quit • Importance of not activating negative side of ambivalence by mandates and reminders of dangers

44. Benzodiazepines • Increased use is over-shadowed by pain pill increase • No overdose deaths • Usually in combination with opioid or alcohol addiction • Hard to convince prescribing physicians, especially psychiatrists, to avoid with addicted patients because of general safety • Important of exceptions

45. Newest Substances: In Pursuit of What Is Not Yet Illegal • Designer drugs, club drugs, salvia • Synthetic marijuana (“spice,” “K2”) • Sold as incense • Use is up to 11% of youth • “Bath Salts” • A synthetic stimulant, can cause psychosis • Active ingredient is cathinone (DEA: Schedule I) • Found naturally in khat (“cot”), a shrub native to East Africa and southern Arabia

46. Thank you