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ADDICTION

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Steve Straubing

on 8 November 2015

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Transcript of ADDICTION

ADDICTION
Steve Straubing, M.D. DABAM, FACOG
Fellow, Addiction Medicine
UF Dept. of Psychiatry
Division of Addiction Medicine
Today's Topics
What is addiction?
Opiates
"Drug addiction is a chronic, progressive, relapsing brain disease characterized by compulsive drug seeking and use despite harmful consequences"
APA
What is addiction?
Opioids

Unfortunately, we don't all speak the same
language. The term 'ADDICTION' does not appear in the DSM IV
DSM IV separates abuse and dependence. DSM V 'lumps them'
In the DSM IV, DEPENDENCE = addiction
However, dependence doesn't = Dependence ???????
Slang terms for Addiction
The authors of DSM IV struggled with the same issues:
Charles O'brien
A definition we can all use
Or more simply, The 4 C's of Addiction:
4 C's of Addiction
Compulsion

Craving
Consequences
Control (loss)
Compulsion
Consequences
Cravings
Loss of control
What Causes Addiction?
Answer: We don't know
We have some pretty good ideas, though
But we have to review some neuroanatomy and physiology
Simplified schematic of neural circuitry in addiction
Just Kidding!!
Two primary concepts
Motivation
Self control
Go =
Stop =
that control all behavior
Brain Correlates
Motivation = limbic system aka reward center, aka "lizard brain"
Stop = Prefrontal cortex aka neocortex, aka telencephalon, aka
judgement center
Biochemical Correlates Of:
Motivate, Go, Reward
DOPAMINE
BIOCHEMICAL CORRELATE Of:
Stop, Self control, Judgement
Multiple neurotransmitters
Glutamate is primary one
"Stop Go" circuitry
How do we know this stuff?
Humans with lesions
Animal studies
Early self administration
Late self administration
Imaging studies
The first phase of addiction is volitional.
DOA usurp the reward center and produce
supra-physiologic release of dopamine. Reward leads to reinforcement and motivates, 'chasing the high'; the body tries
to maintain homeostasis and desensitizes, downregulates, alters function of receptors, etc. and tolerance develops. Hedonic tone is
re set and withdrawal will occur.
First Phase of Addiction
Second Phase of Addiction
Memories assoc. w drugs are formed
and stored. Reward goes down but
PFC changes occur and cognitive control is lost. Drug seeking switches from reward based to craving based. Salience drives dopamine which drives craving, not the drug; the 'go' signal is stuck in overdrive and the 'stop' signal is broken. Neural circuitry has been remodeled and the brain is now 'hijacked'. The person is now addicted and has lost control.
Dopamine
THE HIJACKED BRAIN
RISKS FACTORS FOR ADDICTION
NATURE- GENETICS
NURTURE-ENVIRONMENT (EPIGENETIC)
CO-MORBIDITY
GENDER
UNKNOWN
How else is the brain hijacked?
Complex changes in the HPA axis resulting in synaptic changes CRF neurons with direct connections to the 'Reward Center'
Summary of Brain Changes
1. VTA-Nacc 'go' center
2. Prefrontal cortex 'stop' center with development
of salience, compulsive drug taking
3. Long term memory development with development
of 'cues'
4. Synaptic changes in HPA axis
So what do we treat
when we detoxify
a patient?
Summary of Brain Changes
1. VTA-Nacc 'go' center
2. Prefrontal cortex 'stop' center with development
of salience, compulsive drug taking
3. Long term memory development with development
of 'cues'
4. Synaptic changes in HPA axis
"Drug addiction is a chronic, progressive, relapsing brain disease characterized by
COMPULSIVE
drug seeking and use despite harmful consequences"
APA
In Summary, We go back to the beginning:
Opiates
Derived from the poppy plant (Papaver somniferem)
Residues found in neolithic settlements from 4500 BC
Used recreationally and therapeutically for thousands of years
Mentioned in the Eber Papyrus
Poppy Plant
Opium
Psychoactive alkaloids
Morphine
Codeine
Thebaine
Non psychoactive alkaloids
Papaverine
Noscapine
Opiates
Heroin
Everything else are 'opioids'
Heroin synthesized by Bayer in 1895
OPIATE ACTIONS
All opiates, including endogenous opiates work through the three opiate receptors.
The most active one for pain is the mu receptor where B endorphin works
Mu receptors are widely distributed centrally and peripherally. Largest concentration centrally is in the PAG & Dorsal Horn but also in the Nacc. Peripheral receptors are especially numerous in the gut (constipation)
MOR are in the super family GPCR. There are 3 main subtypes but many splice variants.
How opiates work
They also cause
the release of DOP
GABA
Common Opiates
CLINICAL PEARL
The euphorogenic effects of a drug
and therefore its abusability are
directly related to how fast and how high target receptors respond.
Smoking v IV v NI v Oral
Also related to the PK of the drug
Opioid Metabolism
Treatment Guidelines
Acute overdose
Withdrawal syndrome
Acute OD- Defer to Dr. House
Opiate withdrawal management
Onset of symptoms are related to half life of the drug. Duration of symptoms vary with the drug
Syndrome is not life threatening but it feels that way to the patient
Persistent physiologic derangements may last for up to six months
Two main treatment strategies: 1. Non opioid 2. Opioid
Physical Signs
Most signs are the opposite of those seen
with intoxication
Autonomic instability
Mydriasis
Tremor
Chills
Sweats
Piloerection
Lacrimation
Rhinorrhea
HTN
Tachycardia
Diarrhea
Vomiting
Symptoms
Myalgias
Hot and cold flashes
Anxiety
Agitation
Insomnia
Irritibility
Non opioid treatment
Clonidine 0.1-0.3 mg tid-qid or patch
NSAID's
Antidiarrheal
Anti-emetic
Reassurance
Massage
Opioid Replacement
Use long acting opioid
Full Mu agonist- MTD (can't use here)
Partial Mu agonist-Buprenorphine
Have to wait until in w/d before starting
bupe. 4mg. is a good start. No more than
8 mg. on Day 1. May increase by 4mg/day
to 16mg.
How to monitor therapy?
Bedside eval is best
COWS can quantitate progress
Labs
CBC
CMP
Hep/HIV combo
UDS
Physical
Needle tracks
Murmur, other signs of BE
History
Complete S.A. history-
how long, last use,DOC,route, prior rx, other substances


Family history
- Other users, EtOH, Psych hx
Shx
-recovery environment,childhood, abuse, education
Psych history
-Comorbidity is extremely common
What are the patient's plans re: treatment?
Special considerations
Co-occurring medical conditions
Polysubstance dependence
Pregnancy
Dual diagnosis- Psych and SUD
Collateral- family, friends, PDMP
Thank you!
Questions?
My pager: 352 413 6810
To register for PDMP: Google E-forsce
Arousal
Salience
Memory cues
Email: straubing@ufl.edu
stop
go
Elements of Reward
The consumption of rewards ( food, sex, cocaine) produces pleasure that initiates learning processes that consolidate:
Learning cues that predict its availability and actions that permit its consumption
Liking the rewarding goal
Assigning value and motivational status to the reward so that the organism can select among numerous options to achieve that goal. AKA entrenched learned responses
What does addiction feel like?
An Exercise
" The long experience of humanity with addiction
does not counsel fatalism, but implacable efforts to
overcome the behavioral effects of neural circuits
hijacked by drugs"
Steven E. Hyman in Neuroethics: An introduction with readings
Reisfield GM, Goldberger BA, Bertholf RL. “False-positive” and “false-negative” test results in clinical urine drug testing.
Bioanalysis 2009;1(5):937-952.

Opioid metabolism
Full transcript