Disclosures I have nothing to disclose Updates on the care of - PowerPoint PPT Presentation

3/12/2016 Disclosures I have nothing to disclose Updates on the care of people with addictions Diana Coffa, MD Residency Program Director UCSF Family and Community Medicine New issues in defining Objectives addiction � New DSM 5 criteria � Explore how definitions and language around addiction impact stigma and � Language of substance use treatment � Popular perceptions of addiction � Describe the SBIRT model � Identify and discuss medications that can be used in primary care to treat addiction http://mp3tome.parseapp.com/article/news/2365302/addiction-facts-video-watch/ 1

3/12/2016 DSM 5 criteria for Substance Use Disorder DSM 5 2-3 Mild, 4-5 Moderate, >5 Severe Roles � Recurrent use resulting in failure to fulfill major roles or obligations at work, home, or school Risk � Remove terms abuse and dependence � Recurrent use in hazardous situations Relationship � Recurrent continued use despite social or interpersonal � Replace with spectrum of Substance problems caused or exacerbated by drugs Use Disorder (SUD) � Tolerance � Withdrawal � Craving added as a criterion Craving � Cravings � Problems with law enforcement � A great deal of time getting or using the substance, or removed Compulsion recovering from use � Use of more than intended or for longer than intended Control � Persistent desire or efforts to cut down � Important activities given up or reduced due to Consequence substance use � Continued use despite knowledge of physical or psychological problems Stigma in underserved populations Stigma inducing Stigma mitigating � Addiction treatment is often Addict, Abuser, Junkie, Tweaker limited by Abuse � Shame Clean, Dirty Habit � Low sense of self-efficacy Replacement or � History of failure and fear of Substitution therapy recurrent failure User � Moralistic undertones IVDU PSA 2

3/12/2016 Stigma inducing Stigma minimizing Stigma inducing Stigma minimizing Addict, Abuser, Person with addiction Addict, Abuser, Person with addiction Junkie, Tweaker Person in active addiction Junkie, Tweaker Person in active addiction Person with substance use Person with substance use disorder disorder Abuse Use disorder Abuse Harmful use, risky use Clean, Dirty Clean, Dirty Habit Habit Replacement or Replacement or Substitution therapy Substitution therapy User User IVDU IVDU PSA PSA Stigma inducing Stigma minimizing Stigma inducing Stigma minimizing Addict, Abuser, Person with addiction Addict, Abuser, Person with addiction Junkie, Tweaker Person in active addiction Junkie, Tweaker Person in active addiction Person with substance use Person with substance use disorder disorder Abuse Use disorder Abuse Use disorder Harmful use, risky use Harmful use, risky use Clean, Dirty Negative, positive, discordant Clean, Dirty Negative, positive, discordant Habit Addiction, substance use Habit disorder Replacement or Replacement or Substitution therapy Substitution therapy User User IVDU IVDU PSA PSA 3

3/12/2016 Stigma inducing Stigma minimizing Stigma inducing Stigma minimizing Addict, Abuser, Person with addiction Addict, Abuser, Person with addiction Junkie, Tweaker Person in active addiction Junkie, Tweaker Person in active addiction Person with substance use Person with substance use disorder disorder Abuse Use disorder Abuse Use disorder Harmful use, risky use Harmful use, risky use Clean, Dirty Negative, positive, discordant Clean, Dirty Negative, positive, discordant Habit Addiction, substance use Habit Addiction, substance use disorder disorder Replacement or Treatment Replacement or Treatment Substitution therapy Medication assisted treatment Substitution therapy Medication assisted treatment User User Person who uses… IVDU IVDU PSA PSA Stigma inducing Stigma minimizing Stigma inducing Stigma minimizing Addict, Abuser, Person with addiction Addict, Abuser, Person with addiction Junkie, Tweaker Person in active addiction Junkie, Tweaker Person in active addiction Person with substance use Person with substance use disorder disorder Abuse Use disorder Abuse Use disorder Harmful use, risky use Harmful use, risky use Clean, Dirty Negative, positive, discordant Clean, Dirty Negative, positive, discordant Habit Addiction, substance use Habit Addiction, substance use disorder disorder Replacement or Treatment Replacement or Treatment Substitution therapy Medication assisted treatment Substitution therapy Medication assisted treatment User Person who uses… User Person who uses… IVDU PWID (person who injects drugs) IVDU PWID (person who injects drugs) PSA Person who uses… PSA 4

3/12/2016 Is Addiction a Disease? Two “No” arguments It is a voluntary, hedonistic choice � It is a socially mediated, politically mediated, � culturally mediated, behaviorally mediated, environmentally mediated, complex phenomenon. It is not simply an organic brain disease. Addiction is a complex Is Diabetes a Disease? disease Behaviorally mediated Behaviorally mediated � � Environmentally mediated Socially mediated � � Socially mediated Politically mediated � � Politically mediated Environmentally mediated � � Culturally mediated Culturally mediated � � Emotionally mediated � Not just an organic pancreatic disease � Genetically mediated � Pharmacologically mediated � Organic brain disease � 5

3/12/2016 Natural Reward Elevates Dopamine Addiction as an organic Levels brain disease Disrupted voluntary behavioral control SEX � FOOD 200 DA Concentration (% Baseline) 200 Supraphysiologic dopamine release at nucleus � accumbens 150 % of Basal DA Output 150 � Massive reward 100 100 50 Empty Feeding Box 0 0 0 60 120 180 Mounts Intromissions Time (min) Ejaculations Volkow N et al. Neurobiologic Advances from the Brain Disease Model of Addiction. N Engl J Med 2016; 374:363-371 Jan Source: Di Chiara et al. Source: Fiorino and Phillips 28, 2016 Addiction as an organic Effects of drugs on dopamine release brain disease COCAINE 1100 Accumbens AMPHETAMINE % of Basal Release Accumbens % of Basal Release 400 1000 900 Disrupted voluntary behavioral control � DA 800 300 DA DOPAC 700 Supraphysiologic Dopamine release at nucleus DOPAC HVA � 600 HVA 500 accumbens 200 400 300 � Massive reward 100 200 100 � Increased salience 0 0 0 0 1 2 3 5 hr Over time, diminished intrinsic dopamine release in 4 0 1 2 3 4 5 hr � Time After Amphetamine Time After Cocaine limbic system % of Basal Release 250 MORPHINE NICOTINE Accumbens % of Basal Release 250 � Baseline dysphoric state with decreased reward and Dose (mg/kg) 200 Accumbens 0.5 salience from natural reward stimuli Caudate 200 1.0 150 2.5 Diminished dopamine and glutamate release in 150 10 � 100 frontal cortex 100 � Decreased executive function, impulse control 0 1 2 3 hr 0 Volkow N et al. Neurobiologic Advances from the Brain Disease Model of Addiction. N Engl J Med 2016; 374:363-371 Jan 0 Time After Nicotine 28, 2016 0 1 2 3 4 5hr Time After Morphine Source: Di Chiara and Imperato 6

3/12/2016 Is it harmful to call addiction Why is it useful to call a disease? addiction a disease? People with addiction sometimes describe the � � Reduces stigma disease label as demoralizing or diminishing. � Reduces blame and increases � “It makes it seem like a bigger deal than it is. It’s appropriate response to relapse just a habit that I need to quit. It’s not like there’s something wrong with me.” � Leads to the most effective treatments: Concern that it implies a permanent change that � medication assisted treatments cannot be cured A compromise position SBIRT Model of Care � Treat addiction like a disease � S creening Even if you don’t think it is one � B rief I ntervention --Anna Lembke, MD � R eferral to T reatment 7

3/12/2016 Screening Single Question Screener � USPSTF Grade B recommendation: Annual � How many times in the last year have Alcohol Screening and Brief Intervention for all you had 4 or more (5 for men) drinks in adults one day? � Same as mammograms � 82% sensitive, 79% specific SUD SUD Risky Use Risky Use Low Risk Use Low Risk Use Abstinence Smith et.al. Abstinence J. GIM 2009 Single Question Drug If single question screen is Screener positive � How many times in the past year have � Further assess quantity, consequences, you used an illegal drug or used a and control prescription medication for non-medical � Provide Brief Intervention appropriate to reasons? the level of use. Referral to � 100% sensitive, 73.5% specific for drug use Treatment SUD disorder SUD Brief Risky Use Intervention Risky Use Low Risk Use Screening Low Risk Use Abstinence Smith et.al. Abstinence Arch Int Med. 2009 8