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Addiction to Commonly Abused Medication Dr. Selahattin Kurter, MD Spectrum Healthcare, LLC Westgrove Clinic, LLCDiplomat American Board of Neurology and Psychiatry Diplomat American Board of Addiction Medicine Assistant Professor of Psychiatry, Medical College of Wisconsin
Definition of Substance DependenceAt least 3 of 7 symptoms, which must be met during a 12-month period:• Tolerance• Withdrawal• Longer duration of taking substance or use in greater quantities than was originally intended.• Persistent desire or repeated unsuccessful efforts to stop or lessen substance use.• A relatively large amount of time spent in securing and using the substance, or in recovering from the effects of the substance.• Work and social life impacted negatively because of substance use.• Continued substance use despite negative physical and psychological effects of use.
Neuro-Anatomy of Substance Dependence-Neuro-transmitters-Neuro-transmitter Pathways-Anatomical Structures-Specific Medication/Substance Effect on Neuro chemicals and Pathways
Neurotransmitters in Substance Dependence• Dopamine: – Reward/pleasure system. Vital and evolutionary advantageous behaviors often involve dopamine such as sex and food, etc.• Serotonin (5-HT): – Modulation of anger, aggression, body temperature, mood, sleep, sexuality, appetite• Norepinephine – “Stress hormone” – Involved in alertness and arousal, and influences on the reward system• Endorphines – Endogenous Opioids – Produces sense of well being and analgesia. Secreted during excitement, exercise and sex
Nucleus Accumbens• Major brain reward region. Many projections come from VTA• Important role in reward, laughter, pleasure, addiction, fear, and the placebo effect• Almost every recreational substance causes a significant increase in Dopamine in the Nucleus Accumbens.
VTA (Ventral Tegmental Area)• Part of the pleasure system, or reward circuit, one of the major sources of incentive and behavioral motivation.• Alcohol, Opioids, and Nicotine have a direct affect on VTA by increasing Dopamine release to Nucleus Accumbens.• May play a role in avoidance and fear conditioning due to potential for motivating issues of security and emotions
Amygdala & HippocampusAmygdala:• Involved in fear conditioning• Emotional Regulation• Primary role in the processing and memory of emotional reactionsHippocampus:• Formation of new memories about experienced events• Spatial orientation• Stress affects this area significantly
How does it feel to get high?• Euphoria• “A sense of control”• Less stress (lowers anxiety)• More sociable• More energy (get things done quicker)• “I feel like Superman”
Cycle of Addiction?• Describes cycle of craving, using, withdrawal, and desire to stay “hooked” on the addicting substance. Both physiological and psychological
What Medications are Addicting?• Many medications can be addicting – Tolerance – Withdrawal – Significant “out of control” effects to person’s life – Commonly the following medications have higher risk of addiction: • Opiod (pain medication) • Benzodiazepines (anxiety medications) • Stimulants (ADHD medications)
Dawn (Drug Abuse Warning Network) ERVisitsHigh school opiate, cannabis, and alcohol through 2006 (top down)
Hospital Admissions for Heroin and Prescription Opiod Painkillers 1995 2005 IncreaseUnited States 242,381 317,011 30.79% Illinois 5146 13,381 160.03% Wisconsin 85 1694 1892.94%Substance Abuse and Mental Health Services Administration (SAMHSA). Dept of Health and Human Services.Treatment Episode Data Set (TEDS). 1995-2005. DASIS Series:S-37
Opiod use in Wisconsin• Estimated 192,000 people in Wisconsin used prescription pain relievers inappropriately in 20051• In Wisconsin, rate of 18-25 year old age group using prescription pain pills in past year (13.1%) was higher than national rate of 11.8%2 1.SAMHSA. February 5, 2008. 2. SAMHSA. FEB 4, 2008 2. DEA. Briefs and backgrounds, drugs and drug abuse, state fact sheet, Illinois. Feb 4, 2008.
Opiod Addiction Kills?Risk of Respiratory Depression with Increasing Dose 70 60 50 40 30 20 10 O A E c e n g d o p s t f i 0 Increasing Opioid Dose--->
Risk of Death or Danger• 25% of Opiod addicts die in the first 5 years of addiction• 50% death rate every 5 years when IV heroin is used• Severe co morbidities occur with use: – Endocarditis (heart valve infection) – Hepatitis, HIV – Tooth decay – Cognitive effects – Increase risk of criminality
Benzodiazepines• Group of medications that are used to treat anxiety disorders, muscle disorders, and social phobias• They cause sedation, hypnotic effects, and muscle relaxation• Can be snorting or used IV for a greater sedating effect• More quicker acting and potent “Benzos” are more likely to be abused and develop toleranceCommon Benzodiazepines (“Benzos”):-Alprazolam (Xanax)-Diazepam (Valium)-Lorazepam (Ativan)-Clonazepam (Klonopin)-Temazepam (Restoril)
“Benzos”• Long term use or misuse can cause or worsen cognitive deficits, depression and worse anxiety• Abrupt discontinuation can lead to seizures and death• Withdrawal effects include tremors, agitation, sweating, confusion, increased anxiety• Moderate to severe withdrawal should be managed medically (i.e. inpatient detox) to prevent risk of death due to seizures
“Benzos”• 10% of patients have protracted withdrawal syndrome, which can persist for months to 1 year• Overdoses usually do not lead to death unless it is mixed with opioid or other sedatives (i.e. Alcohol)• 80 percent of abuse is part of poly-drug abuse, most commonly with opioid or alcohol• 30-40% of Alcoholics have reported abusing “Benzos” some time in their life• 15% of heroin users report daily use of “Benzos”
Stimulants-Amphetamines• Used to treat Attention Deficit Hyperactivity Disorder (ADHD) and some types of depression• Most potent forms derived from Amphetamine derivatives, such as dextroamphetamine• Causes increase in dopamine. Effects include increased focus, increased heart rate, increased blood pressure, sweating, increased cognitive functioning• If abused or in high dosages, effects are euphoria, “confidence,” grandiosity, irritability, increased sex drive, and weight lossCommon Stimulants:-Adderall-Adderall XR-Dexedrin-Ritalin
Stimulants-Amphetamines• Toxicity occurs with repeated use – Hypertension leading to stroke or brain hemorrhage – Cardiac Arrhythmia leading to cardiac failure• Abrupt discontinuation can lead to acute depression and apathy in 50% of abusers• 80% of amphetamine abusers report hallucinations (visual and auditory)• Chronic abuse of amphetamines may lead to loss of dopamine regulation resulting in long term cognitive and emotional imbalance
Treatment• Necessity of individualized treatment• Inpatient Detox, Day treatment, Outpatient treatment – Psychotherapy • Group therapies (AA model, 12 steps) • Individual therapy for drug addiction – Medication Management • Last 10 years great advancement in understanding of neurobiology of addiction • Evidence based treatments are augmentative to psychotherapy • Must address both the biology and psychology of addiction