Dr. George Kolodner presents "Update on Addictions

1. Update on
Addictions
George Kolodner, MD DLFAPA
FASAM
Chief ClinicalOfficer
Kolmac OutpatientRecovery Centers
ClinicalProfessorof Psychiatry
Georgetown University and
University of Maryland Schoolsof
Medicine

2. Overview
• Recent Use Patterns
• Relapse Prevention
• Specific Substances

3. Technology

4. 32
23
17 15
11 9 9
5 4
0
5
10
15
20
25
30
35
Percentage of People Addicted After Using A
Substance

5. • Nicotine: 50 – 67%
– Predictors of progression from use to addiction:
• Unmarriedfemale,lowerage
• Anxietydisorderandabsenceofdepression
• Cannabis: 17 – 25%
• Alcohol: 16%
– Predictors of progression from use to addiction:
• Unmarriedmale,nicotineaddictionwithlowerage,
income,andeducation
• Depressionbutnotanxietydisorder
Risk of Addiction: Weekly Users

6. Substance Use by Teenagers, 2016
(www.monitoringthefuture.org)
• Declines for most substances
– Historiclowsforalcohol,tobacco,heroin,inhalants
– Decreasedstimulants,MDMA(“ecstasy”),cocaine
• Cannabis
– 8th graders:decreased
– 10th and12th graders:noincrease
– Continueddeclineforsyntheticcannabis(“K-2,”"Spice")
• Prescription opioids decreased
• Electroniccigarettesdeclined for first time
– Exceedconventionalcigarettes

7. 2015 Substance Use Trends: College Aged
(www.monitoringthefuture.org)
• Reduction in almost all substances
– Alcohol: reduced regularand binge
• Stillcommon
– Tobacco:non-students > students
• Shifttoelectronicvaporizers
– Pain pills continue to decline (peakedin 2006)
– Stimulants: prescription and non-prescription
including MDMA (“ecstasy”)
• Cannabis: increased but daily use is still
below 2014 peak

8. Changes in Substance Use
by Kolmac Patients
1989 2016
Cocaine 44% 9%
Opioids 6% 33%
Marijuana 6% 18%
Benzodiazepines 2% 8%

9. RELAPSE PREVENTION

10. Treating Relapsing Patients at Kolmac
• Philosophy
– SUD as chronic illness
– Importance ofcontinuity
• Program design
• Patients
– Co-occurring psychiatric issues
– Total:302
• Response
– Patients
– Insurance companies

11. Relapse Triggers:
Neurotransmitters and Location
1. Exposure to the substance
– Dopamineandendorphin
– Prefrontalcortex,nucleusaccumbens,ventralpallidum
2. Drug associatedcues (“People,places, and things”)
– Dopamine,glutamate,andendorphin
– Prefrontalcortex,amygdala,anteriorcingulategyrus
3. Stress
– Corticotropin-releasingfactor(CRF),norepinephrine
– Bednucleusofthestriaterminalis

12. Opioids and Stress
• Addictive use of opioids creates persistent
disruption of hypothalamic-pituitary-
adrenal stress system
– Abstinence: Hyper-responsive
– Heroin: Hypo-responsive
– Methadone: Normal

13. Reducing Stress Induced Relapses
• Withdrawal from opioids and alcoholis
associatedwith excessivenorepinephrine
activity in the brain stem (locus coereleus)
– Causeacuteanxietyandagitation
– Causelongerlastingsensitivityofstressregulating
system
• Alpha-2adrenergicagonists moderatethe
excessiveNE activityand relievewithdrawal
– Clonidine,Tenex(guanfacine)
• New: longer term use of alpha-2agoniststo
disconnectstress pathway to reducerelapse

14. TOBACCO

15. FDA Regulations Regarding
Tobacco Addiction Treatment
• Removed black box psychiatric warning on
varenicline(Chantix)

16. E-Cigarettes (“Vaping”)
• Alternative nicotine delivery system
• Liquid is heated in a battery operated
device that creates an aerosol that is
inhaled
– Not actuallya vapor, but rather fine particles
• Liquid contains nicotine, flavoring, and
other ingredients
– No uniformity ofproduct content
• “Momandpop”storesmakeownmixtures
– Heating ingredientcreatesbyproducts
• Propyleneglycolpropyleneoxide(carcinogen)

17. Youth: Shifting From Tobacco
to E-Cigarettes
Year Tobacco E-Cigarettes
2015 9% 16%
2011 16% 1.5%

18. Concerns About Use by Youth
• Some teens are starting with e-cigarettes
and transitioning to regular tobacco
• NIDA: new project underway for
prospectivestudy of the effect of all
substances on adolescent brain and
cognitive development
– Baseline studies being done of9 and 10 year
old's, including MRIs

19. E-Cigarettes: Recent Developments
• New FDA regulations extends 2009 tobacco
regulations to e-cigarettes,cigars, hookah
and pipe tobacco
– No sales to youth younger than 18
– Ingredientsexaminedfor health impact
• Entry into the field by tobacco industry
• Devices arebeing used for illicit substances
• Increase in use is slowing

20. E-Cigarettes: Future Directions
• Can be useful for some people who are
using them to quit tobacco
• Increase in harm reduction consideration
– “Dangersexaggerated”

21. CANNABIS (AKA MARIJUANA)

22. Latest Studies on Use
• Increasein number of use by young adults
and older adults but not in teenagers,
despite liberalization of cannabis laws
• Dramatic reduction in use of synthetic
cannabinoids (spice, K2) as a result of
– Increasedenforcementof laws
– Increasedawarenessof negativeeffects

23. Negative Effects on
Developing Nervous System
• Heavy cannabisuse
– Prospectivestudyof1,000frombirthto38 found
cognitivedeficitsifheavyusebeganbeforeage18
• IQ(8points,norecovery)
• Attention(poorrecovery)
• Memory,processingspeed,reasoningskill
• In utero
– Decreasedheadcircumference
– Cognitiveandbehavioraleffectsafterage4
– Colorado:increaseinbabiesbornwithTHCintheir
systems

24. Availability of Cannabis for Research
• Failureof Congressionalbill to createnew
Schedule“1R”for cannabisresearch
• DEA:
– RejectedchangingSchedule1statusforcannabis
– Willallowmultiplesuppliersforresearchgrade
productionbutasofnowthereisonlyasingle
supplier
• NIDA is working with theDEA to reduce the
administrativeburdens on research
– CBDwillbeavailableforresearchstudies

25. Expanded Research
• NIH Cannabis NeuroscienceResearch
Summit, March 22-23, 2016
– Recording of conferenceavailableat:
https://videocast.nih.gov/summary.asp?Live
=18464&bhcp=1
• More balanced approach at American
Society of Addiction Medicine Annual
Meeting

26. Raphael Mechoulam
• 86 y.o. Israeli chemist, still professionally
active
• Identified THC as the primary psychoactive
ingredient in cannabis
• Discovered the endocannabinoid system
• “The Scientist”: YouTube documentary
about his discoveries
– https://www.youtube.com/watch?v=csbJnBKq
wIw

27. Pharmaceutical: “Entourage Effect”
• Sativex (1:1 ratio of CBD/THC)
– Oro-mucosal spray
– Approved in 25 countries (2005) for spasticity from
multiple sclerosis, cancerpain, neuropathic pain
– U.S.: Phase IIIclinicaltrials, fast trackedby FDA in
April, 2014
• Epidiolex (cannabidiol or CBD)
– Purified liquid extract
– Anticonvulsant for Dravetsyndrome
– Orphan Drug Status from FDA, pre-IND

28. Efficacy of Medical Cannabis
• High quality evidence
– Chemotherapy-inducednauseaandvomiting
– Appetitestimulation
– Chronicpain,neuropathic(especiallyHIV/AIDS)
– Spasticityof multiplesclerosis,spinalcordinjury
– Anticonvulsant(CBDforDravetSyndrome)
• Low quality evidence
– Anxiety,sleepdisorders,PTSD
• Possiblerole in addictiontreatment
– Reducecannabiswithdrawal
– CBDcounteractspsychoactiveeffectof THC
– CB1blockerrimonabantwithdrawn2008

29. Health Effects of Cannabis
• Comprehensivereview released January,
2017 by National Academy of Science
– http://nationalacademies.org/hmd/Reports/20
17/health-effects-of-cannabis-and-
cannabinoids.aspx

30. Important Unresolved Issues
• Restricting access by teenagers
• Drugged driving
• Quality control of artisanal “medical
marijuana”
• Concerns about impact of investors and
commercial advertising

31. Current Legal Status
• Legal for medicaluse in 29 statesand DC
– Pendingin2,2017legislationfailedin13
• Legal for recreationaluse in 8 statesand DC
– Cannotbebroughtacrossstateborders,evenin
adjacentstates
• Maryland
– Decriminalizedfor recreationaluse
• LegalizationbillfailedinMarylandLegislaturethisyear
– Legalizedfor medicalusesince2013
• Patientsarenowabletoregister
• Availabilityexpectedby“endofSummer”
• http://mmcc.maryland.gov/Pages/home.aspx

32. Future Cannabis Policy
• “Campaign2016wasthefirstpresidentialracein
whichmarijuanareformwastreatedasa legitimate,
seriouspublicpolicyissue.Itwasimportantenough
sothatthosevying tobepresidentsof theUnited
Statesnotonlywereaskedabouttheirhistorywith
thedrugbutwerealsoexpectedtodeveloppolicy.”
(JohnHudak,Marijuana:A ShortHistory,p.115)
• ObamaDOJ policytoward“medicalmarijuana”of
“cooperativenoninterference"is beingreviewedby
TrumpDOJ
• July,2017:billto legalizewasintroducedin U.S.
Senateby CoryBooker

33. OPIOIDS

34. Rates of Opioid Sales & OD Deaths, 1999–2013
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Source:NationalVitalStatisticsSystem,DEA’sAutomationofReportsandConsolidatedOrdersSystem

35. Prescription of Opioid Analgesics
• CDC issued new guidelines for reducing the
prescribing of opioid analgesics
• AMA recommends removing pain as “5th vitalsign”
• CMS removedpatient satisfactionquestions
regardingopioid prescribing from Hospital
Consumer Assessment of HealthcareProviders and
Systems (HCAHPS)
• FDA panel recommended extending REMS
– Mandatorytrainingforopioidprescribing
– InstantreleaseformulationsnowIncluded
• Increasedrequirements for physicians to registerfor
and use PDMPs
• Increasededucation and convenience regarding
disposal of unused medication

36. CDC Guidelines: Prescription of Opioid
Medications for Chronic Pain
1. Non-pharmacologic and non-opioid
pharmacologic therapies are preferred
2. Beforestarting, discuss risks and benefits,
reasonablegoals for pain and functioning,
and have plan for discontinuation
3. Begin with immediate-releaseinstead of
extended-release/long-acting (ER/LA)
opioids
4. Periodically reevaluate and work to lower
dose or discontinue

37. CDC Guidelines: Prescription of Opioid
Medications for Chronic Pain
5. Use urine testing before starting and
periodically thereafter
6. Use Prescription Drug Monitoring Program
(PDMP)
7. Avoid using opioids for patients taking
benzodiazepine medication
8. Screen for history of substance use
disorder

38. Opioid Related Overdose Deaths United States,
1999-2013

39. Death Rates by Age Group from Overdoses of
Heroin or Prescription Opioid Pain Relievers
SOURCE: CDC. Increases in Heroin Overdose Deaths — 28 States, 2010 to 2012
MMWR. 2014, 63:849-854

40. Continued Rise in Opioid
Overdose Deaths
• Caused by the addition of potent synthetic
opioids to heroin
– Fentanyland carfentanil(animaltranquilizer)
arebeing produced illicitlyin China rather than
divertedfrom legitimatemedicaluse
• OverdoseofPrincewasonfentanyl
• Third wave, after prescription opioids and
heroin

41. Kratom
• Derived from leaves of Southeast Asian tree
• Active ingredient: mitragyna alkaloids
• Low dose: stimulant effect
• Higher doses: activates opioid receptors
and can relievepain
• Used for centuries for medicinal purposes
• Addictive use resembles opioids
• Under political pressure, DEA reversed its
decision to place it in Schedule 1

42. • Cumulative: 5,030
• Admitted in 2016: 501
• Current: 287
– Longerthan 1 year:39%
– Longerthan 2 years: 24%
– Variationby office:
• Baltimorearea:76%
• Washingtonarea:24%
Buprenorphine for Kolmac Patients

43. Expanded Use of Buprenorphine
• Overonemillionpatientsnowtakingit
– Comparetoquartermilliononmethadone
• Incorporationintotraditional12-Stepbased
residentialtreatmentprogram
– Hazelden/BettyFordproject
• Increasedpatientlimitto 275forphysicians:
– Withaddictioncertification
– Whohavehadawaiverforthe100patientlimitforat
leastoneyear
– Orwhopracticeinaqualifiedhealthsetting(provide
counselingandacceptinsurance)
• NPsandPAs nowallowedto prescribe(30 100)

44. Diversion of Buprenorphine
• Maryland Medicaid forced conversion of
many patients off of Suboxone because of
complaints of State law enforcement about
diversion of that formulation in jails and
prisons
– Effortsunderway by addiction specialists to
reconsider this decision
• Street use for relief of withdrawal rather than
euphoria

45. • Treatmentstaff
– Negativemethadoneexperiences
• Patients
– Concernaboutgettingoff
– “Notreallyinrecovery”
• Patientfamilies
– Negativepublicity
– “Exchangingonedrugforanother”
• Addictiontreatmentcommunity
• NarcoticsAnonymous
– “Unabletoworkthesteps”
• HHS Secretary,TomPrice
• Lobbyingby Alkermes(manufacturerofVivitrol)
Addressing Resistances

46. • Prior authorization:now banned in Maryland
• Stabilizationdoses
– Varybyindividual
• Co-morbid pain management
– Chronic
– Electivesurgicalprocedures
• Specializedgroup vs. integratingwith other
substanceusers
• Discontinuing
– When:taskversustimebased
– How: protocols,Butranspatch
– Relationshiptolongtermrecovery
Ongoing Issues With Buprenorphine

47. • Integrating with outside community
– “Warm handoff” study atUniversity of
Maryland Hospital
– Initiatingtreatmentin ED with coordinatednext
day continued treatmentwith collaborating
treatmentprograms
– Shifting patientto primary care physician
• Use of one day dose in withdrawal
management protocol to expedite
naltrexoneinduction
Future Possibilities

48. BENZODIAZEPINES

49. Prescription of Benzodiazepines
• Steady increasein number of prescriptions
being written
• Concern about interaction with opioids
– FDA black box warning on co-prescribing of
benzodiazepinesand opioid analgesics
– FDA is reviewingco-prescribing of
benzodiazepineswith opioids for medication
assisted therapy

50. POLICY ISSUES

51. War on Drugs
• Wound down under Obama administration
– Presidentialcommuting of sentences ofnonviolent
drug offendersin federalprisons relatedto earlier
decision to eliminatedisparity betweensentences
for powdered and crack cocaine
– Justice Department decision to phase out use of
privateprisons that had grown due to waron
drugs
• Possible resumption under Trump
administration
– AG Sessions threatensincreased prosecution of
cannabis use and suggests return to “Just say no.”

52. Renewed Interest in Harm Reduction
• Needle exchange
• Protected sites for heroin use
• Decriminalization
– Cannabis in Canada
– Totalin Portugal

53. Impact of Policy Changes on Addiction Treatment
• Affordable Care Act changed reimbursement
formulas to incentivizecost-effectivetreatment
– Penalizing hospitals for 30 day readmissions
• “Warmhandoffs”researchatUniversityofMaryland
– CareFirstreducing or eliminating large
deductibles for addiction treatment
• Maryland HospitalServicesCost Review
Commission
– Establishedglobalbudgetsandincentivesfor
hospitalstopartnerwithcommunityproviders
• Projecttoembedaddictionandmentalhealthclinicians
fromKolmacandSheppardPrattintoGBMCprimarycare
practices

54. President’s Commission on Combating Drug
Addiction and the Opioid Crisis, 7/31/17
• Declarenational public health emergency
• Expand addiction treatment capacity
• Mandate prescribereducation on opioids
• Fund access to medication assisted
treatment, including all 3 options
• Increase interstate capacity of Prescription
Drug Monitoring Programs (PDMP)
• Enforce parity for behavioral health

55. Professional Learning Opportunities
• American Society of Addiction Medicine
(ASAM) Associate Membership
– Access to publications, educationalevents
– Maryland/DC Societyof Addiction Medicine
(MDSAM)
– $260

56. Thank you
GeorgeKolodner,M.D.
gkolodner@kolmac.com
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