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Opioid Abuse�

Alan Groveman, Ph.D, ABPP

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Learning Objectives

Understand what opioids are and how they impact people
Explore the environmental factors contributing to opioid misuse
Recognize four signs of opioid misuse and addiction
List three opioid treatment approaches

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Opiates

Opiates: A Natural Pain Remedy

Opiates are alkaloids derived from the opium poppy. Opium is a strong pain relieving medication, and a number of drugs are also made from this source.

Types Of Opiates

Morphine
Codeine
Heroin
Opium

Opium Poppy

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Opioids

Opioids: Synthetic Pain Medications

Opioids are synthetic or partly-synthetic drugs that are manufactured to work in a similar way to opiates. Their active ingredients are made via chemical synthesis. Opioids may act like opiates when taken for pain because they have similar molecules.

Types Of Opioids

Methadone
Percocet, Percodan, OxyContin (oxycodone)
Vicodin, Lorcet, Lortab (hydrocodone)
Demerol (pethidine)
Dilaudid (hydromorphone)
Duragesic (fentanyl)

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Most Commonly Used Opioids & Opiates

Heroin Hydrocodone
Codeine Oxycodone
Demerol Levorphanol
Morphine Vicodin
Darvocet OxyContin
Fentanyl Tylenol 3
Dilaudid Tylox
Methadone Percocet
Opium Percodan

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Opiates & Opioids

Both of these types of drugs alter the way that pain is perceived, as opposed to making the pain go away.

They attach onto molecules that protrude from certain nerve cells in the brain called opioid receptors.

Once they are attached, the nerve cells send messages to the brain that are not accurate measures of the severity of the pain that the body is experiencing. Thus, the person who has taken the drug experience less pain. However, overtime once tolerance develops the experience changes.

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Prescription Drug Abuse

Nearly 50% of teens abusing prescription opioids find them in their own homes, in the homes of family members, or at a friend’s house.

Some teens are legitimately being prescribed opioids “medications” by licensed physicians. Many due to injuries while playing sports.

Others buy them off the street or at school. These types of drugs are highly addictive and as the demand grows so does the price.

Some of the higher milligram doses are selling for as much as $60 to $80 per pill.

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Pain Relief

Opioids can relieve moderate to severe pain.

If taking opioids 8 days or longer on a regular basis, withdrawal symptoms may occur, one may need to be weaned off medications slowly.

After 8 days there is a 13.5 % chance of becoming addicted. After 30 days there is a 29.9% chance of developing addiction.

When people use pain medications only to treat pain as directed and for a short time, they are less likely to become addicted.

Prescription drug addiction occurs when patients develop a tolerance for the level of medication they have been described and no longer get the same level of relief.

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Pain Management

Patients may not have the same expectations for relief as their physicians and may equate the term “painkillers” with the medication being able to take away all of their pain, while their doctor may be thinking in terms of pain management, which means bringing the pain to a level where they can function at a reasonable manner.

When expectations do not match, patients may take more of the pain medication than prescribed to get a higher level of relief and in turn develop a drug addiction issue.

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Addiction

Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.

It is considered a brain disease because drugs change the brain; they change its structure and how it works. These brain changes can be long lasting and can lead to many harmful, often self-destructive, behaviors.

National Institute on Drug Abuse, 2007

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Substance Use Disorders are Diseases

Substance use disorders are brain diseases mostly characterized by a person’s inability to control his or her thoughts or intake of a substance.

A substance use disorder develops after a substance is repetitively consumed and the brain readjusts to its consistent presence.

Research shows that adaptations in neuronal functioning occur regardless of whether a person is taking legitimate medication for pain relief, consuming five beers as a first time drinker or injecting heroin on the streets.

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Withdrawal

Heroin and other Opiates causes severe physical and psychological symptoms 6 to 8 hours after the last dosage. Painful withdrawal gets worse as time passes.

Symptoms Include:

Runny nose, muscle and bone pain
Emotional distress and restlessness
Diarrhea
Vomiting
Hot flashes and heavy sweating
Cold flashes with goose bumps
Insomnia
An overwhelming need for more heroin or opiates
Hence the cycle to avoid the painful withdrawal

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Predisposition for Addiction

Genetic Factors- Account for about half of the likelihood that an individual will develop addiction.

Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence.

Resiliencies the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavioral and other manifestations of addiction.

American Society of Addiction Medicine, 2011

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Predisposition for Addiction

Culture also plays a role in how addiction becomes actualized in persons with biological vulnerabilities to the development of addiction.

Other Factors- Stress, trauma, lack of healthy support etc.

No single factor will determine whether a person will become addicted to drugs or not.

American Society of Addiction Medicine, 2011

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So What’s the Problem?

1 of 5 patients without cancer pain or pain related diagnoses are prescribed opioid pain medications.
Nearly 2 million Americans abused or were dependent on prescription opioids in 2014.
From 1999-2015 more than 180,000 people died from an overdose related to prescription opioids.
As many as 1 in 4 patients prescribed opioids for chronic pain develops a opioid use disorder.

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Prescription Opioid �Abuse Often Leads to Heroin Abuse

4 out of 5 new heroin users started misusing prescription opioids¹

¹Hedegaard MD MSPH, Chen MS PhD, Warner PhD. Drug-Poisoning Deaths Involving Heroin: United States, 2000-2013. National Center for Health Statistics Data Brief. 2015:190:1-8.�

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Fentanyl Crisis

Fentanyl

Synthetic and short-acting opioid analgesic

100X more potent than Morphine

50X more potent than Heroin

Primary use is for managing acute or chronic pain associated with advanced cancer

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LETHAL DOSE

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LETHAL DOSE OF FENTANYL

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Carfentanil

An synthetic opioid used by veterinarians to sedate large animals such as elephants.

NOT intended for human consumption

Up to 2,500 times stronger than heroin

Emerged recently in many parts of the US

EXTREMELY LETHAL

Immediate death for many

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What Is An Opioid Overdose?

Opioids fit into specific pain receptors in the brain which affect the drive to breathe:

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Opioid Overdose

Overdose can occur immediately after drug ingestion OR could happen hours after drug ingestion

Overdose can last up to a couple of hours where the overdose victim experience respiratory depression

Fentanyl related overdoses tend to:

Happen instantaneously
Narrow window of time available to rescue the victim
Require additional doses of naloxone to reverse effects of opioids
Victims die from suffocation not the drug

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Naloxone, also known to many by its brand name, Narcan, has saved tens of thousands of lives by reversing overdoses.

Some patients have received 10-12 doses of Narcan to revive them. Some people cannot be saved.

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Intranasal Medication Delivery

Champaign County Sheriff's Office

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RECOGNIZING SIGNS OF DRUG USE

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SIGNS OF BEING UNDER THE INFLUENCE OF AN OPIATE

Pinpointed Pupils: Opiate (Pain-pills, Heroin, Fentanyl, Morphine, Codeine)

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OTHER SIGNS OF BEING UNDER THE INFLUENCE OF AN OPIATE

Drowsiness, lethargic, nodding off

Scars or track marks from injecting the drug

Excessive scratching at skin

Blank stare, slow reaction time, slow speech

Shallow breathing

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Treatment

The goal of addiction treatment is always to assist a client in stopping the compulsive use of drugs or alcohol and progress to living a normal, functional life.

Addiction creates a host of negative effects to the dependent client, his or her family and friends and society as a whole.

Research has shown that the most effective treatment regimen for opioid use disorders is a combination of medication assisted treatment, with cognitive behavioral therapy, and person centered therapy.

I think we can all agree that the goal of addiction treatment is always to assist a client in stopping his or her compulsive use of drugs or alcohol so they may progress into a normal, functional life.

There are many steps that are necessary to achieve this goal and there are many people invested in its success. Addiction creates a myriad of negative effects to the dependent client, his or her family and friends and to society as a whole. It is important to remember that any reduction in use or step towards sobriety benefits the lives of many individuals and must not be undervalued.

So when considering pharmacotherapy for a substance use disorder, the risk of continued to all involved parties, the possible side effects and the benefits of the medication must be discussed. Remember, some of these benefits can be more subtle, such as reducing absenteeism from work or reduction in family conflict.

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Medication Assisted Treatment (MAT)

The medication is only one aspect of treatment.

The medication is intended to help prevent relapse while the addicted individual works to make lasting behavioral changes.

A full treatment continuum should take place along with MAT; counseling and meetings are necessary for lasting recovery.

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Opioid Treatment Programs�May Offer the Following�Services

Medication Assisted Treatment

Long term substance use disorder treatment (at least 18 months)

Non-traditional case management

Psychologist

Family involvement

Peer recovery coaching

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Opioid Treatment Programs�Evidence- Based Programs

Motivational Interviewing

Cognitive Behavioral/Person Centered Therapy

Family/Couple Therapy

12 Step Involvement

Spiritual Support

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Opioid Treatment Programs�Comprehensive MAT Program

Detox

Residential (if needed)

Intensive Outpatient Program (IOP)

Outpatient Program (OP) 8 weeks

Aftercare/continuing care groups 10 weeks

Non-Traditional Case Management (Weekly sessions while on MAT)

12 Step meetings weekly

Psychiatric Care (Monthly sessions or more if required)

Individual Counseling (Weekly sessions while on MAT)

Physician Follow ups (as required)

Medical Care

(As required)

Urine Screens (Random weekly while on MAT)

Recovery Housing

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Assessing Readiness to Change

When an addiction professional first interacts with a substance dependent client, the client may not be ready to stop using illicit drugs and/or alcohol.

Even clients expressing the desire to stop using will have ambivalent feelings about the change process.

In order for clients to experience sustained behavior change, they must voluntarily desire for their lives to be different.

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Assessing Readiness to Change

However, clients enter treatment at varying stages of readiness for treatment and openness to counseling.

Some are eager, and some are looking for the door as soon as they sign in.

And experience has shown that some treatment interventions are better suited for particular types of clients, while others are best used at specific time periods during the treatment process.

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Stages of Change Model

The Stages of Change Model identifies six independent stages of behavior and thinking that clients can experience during the treatment process.
By identifying which stage of change a client is currently in, addiction professionals can better understand the treatment needs of that client and which treatment options are most appropriate.

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Medication-Assisted Treatment

The single most accurate predictor of successful treatment outcome is the length of time in treatment. Pharmacotherapies can:

help clients remain in treatment longer
achieve complete abstinence
help prevent relapse
reduce frequency and amount of consumption
help them continue to stay committed to meeting their treatment goals and maintain long-term recovery.

Pharmacotherapies are effective. Clinical data suggest that clients perform better in treatment when psycho-social-educational-spiritual therapy is combined with appropriate pharmacotherapies.

Medications can serve as a tool to initiate treatment.

I think this next statement is the most relevant point in favor of pharmacotherapies.

Research shows that the single most accurate predictor of successful treatment outcome is the length of time in treatment. This means that any interaction with the treatment process increases the chance a client will remain sober. Data shows that medications can help a client stay in treatment longer, achieve complete abstinence from psychoactive substances, help prevent relapse, reduce substance consumption, continue to stay committed to meeting their treatment goals and maintain long-term sobriety. Every day that a client chooses to take his or her medication, he is reaffirming the commitment to staying sober and is staying engaged in the treatment process. This in turn will increase his chances of success.

Further, clinical data suggests that clients perform better in treatment when psycho-social-educational-spiritual therapy is combined with the appropriate pharmacotherapy.

Later in the program, I will present efficacy data for several of the medications we discuss today.

Finally, medications can serve as a tool to initiate treatment. Even when clients are not ready to change, even a discussion about medication options can get the ball rolling. Stay tuned: we will discuss this more in depth later in the program.

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Benefits of MAT

MAT of opioid addiction is associated with:

Decreases in the number of overdoses from heroin abuse.

Increases retention of patients in treatment.

Decreases drug use, infectious disease transmission.

Decreases in criminal activity. (SAMHSA, 2014)

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TREATING OPIOID DEPENDENCE WITH MEDICATIONS

There are 3 medication options for treating opioid dependence

Full agonist
Partial agonist
Antagonist

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TREATING OPIOID DEPENDENCE WITH A FULL AGONIST

Full opioid agonists attach to opioid receptors in a similar manner as opioid drugs like heroin or OxyContin

Methadone is a full agonist:

One does not have to withdraw before starting a full agonist
One will experience withdrawal when they stop taking a full agonist
Full agonists prolong dependence �on opioids
Full agonists prevents withdrawal symptoms

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TREATING OPIOID DEPENDENCE WITH A FULL AGONIST

One type of medication is referred to as a full opioid agonist.

Methadone is an example of a full agonist. It attaches to and stimulates the opioid receptors in a similar manner as opioid drugs like heroin or OxyContin (Oxycodone HCl) do, but with protective or normalizing effects when taken as directed^1,2
You don’t have to detox if you want to begin treatment with a full agonist, but you will experience withdrawal when you stop taking the drug²
Full agonists prolong your physical dependence on opioids²
Discuss all benefits and risks of full agonist medications with your medical doctor

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TREATING OPIOID DEPENDENCE WITH A PARTIAL AGONIST

Partial opioid agonists attach to opioid receptors and partially activate them

SUBOXONE^® (buprenorphine) is a partial agonist:

Partial agonists still stimulate the brain’s opioid receptors, but not as much as full agonists
One does not have to withdraw before starting a partial agonist
If one stops a partial agonist abruptly, they will experience withdrawal
Partial agonists prolong physical dependence on opioids

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TREATING OPIOID DEPENDENCE WITH A PARTIAL AGONIST

Another type of medication is a partial opioid agonist. Partial opioid agonists attach to opioid receptors and partially activate them¹

SUBOXONE (buprenorphine and naloxone) is an example of a partial agonist¹
Partial opioid agonists still stimulate opioid receptors, but to a lesser degree than full agonists^1,2
You don’t have to detox before starting a partial agonist¹
If you stop a partial agonist abruptly, you’ll experience withdrawal¹
Partial agonists will prolong your physical dependence on opioids¹
Discuss all benefits and risks of partial agonist medications with your medical doctor

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TREATING OPIOID DEPENDENCE WITH AN ANTAGONIST �OR BLOCKING MEDICATION

Opioid antagonists attach to opioid receptors but don’t trigger them

Naltrexone/Vivitrol is an Antagonist:

One must withdraw before starting an antagonist
Antagonists are non-addictive and won’t lead to physical dependence
One will not experience withdrawal when stopping an antagonist

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TREATING OPIOID DEPENDENCE WITH AN ANTAGONIST OR BLOCKING MEDICATION

Another way to treat opioid dependence is with a nonaddictive, blocking medication—called �an opioid antagonist.^1,2

Opioid antagonists attach to opioid receptors, but don’t trigger your brain’s �pleasure response^1,2
You do have to detox before starting an antagonist^1,2
Antagonists are nonaddictive and won’t lead to physical dependence¹
You won’t experience withdrawal when stopping an antagonist¹
Discuss all benefits and risks of antagonist medications with your medical doctor

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Any Questions Please Email me: njpsych@gmail.com

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7 MYTHS About MAT

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�MYTHS About MAT

MYTH #1:

MAT Trades One Addiction For Another

FACT: MAT bridges the biological and behavioral components of addiction. Research indicates that a combination of medication and behavioral therapies can successfully treat SUDs and help sustain recovery.

-National Council for Behavioral Health

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MYTHS About MAT

MYTH #2:

MAT Is Only For The Short Term

FACT: Research shows that patients on MAT for at least 1-2 years have the greatest rates of long-term success. There is currently no evidence to support benefits from cessation.

FACT: Patients with long-term abstinence can follow a slow taper schedule under a physician’s direction, when free of stressors, to attempt dose reduction or total cessation.

-National Council for Behavioral Health

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MYTHS About MAT

MYTH #3:

Many Patients’ Addiction Conditions Are Not Severe Enough to Require MAT

FACT: MAT utilizes a multitude of different medication options (agonists, partial agonists and antagonists) that can be tailored to fit the unique needs of the patient.

-National Council for Behavioral Health

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MYTHS About MAT

MYTH #4:

MAT Increases The Risk For Overdose In Patients

FACT: MAT helps to prevent overdoses from occurring. Even a single use of opioids after detoxification can result in a life-threatening or fatal overdose. Following detoxification, tolerance to the euphoria brought on by opioid use remains higher than tolerance to respiratory depression.

-National Council for Behavioral Health

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MYTHS About MAT

MYTH #5:

Providing MAT Will Only Disrupt and Hinder a Patient’s Recovery Process

FACT: MAT has been shown to assist patients in recovery by improving quality of life, level of functioning and the ability to handle stress. Above all, MAT helps reduce mortality while patients begin recovery.

-National Council for Behavioral Health

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MYTHS About MAT

MYTH #6:

There Isn’t Any Proof That MAT Is Better Than Abstinence

FACT: MAT is evidence-based and is the recommended course of treatment for opioid addiction. The National Institute on Drug Abuse, Substance Abuse and Mental Health Services Administration, National Institute on Alcohol Abuse and Alcoholism, Centers for Disease Control and Prevention, and other agencies emphasize MAT as first line treatment.

-National Council for Behavioral Health

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MYTHS About MAT

MYTH #7:

Most Insurance Plans Don’t Cover MAT

FACT: As of May 2013, 31 state Medicaid FFS programs covered methadone maintenance treatment provided in outpatient programs.

State Medicaid agencies vary as to whether buprenorphine is listed on the Preferred Drug List (PDL), and whether prior authorization is required (a distinction often made based on the specific buprenorphine medication type). Extended-release naltrexone is listed on the Medicaid PDL in over 60 percent of states.

-National Council for Behavioral Health

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QUESTIONS?