S. Alex Stalcup, M.D. New Leaf Treatment Center 251 Lafayette Circle, Suite 150 Lafayette, CA 94549 Tel: 925-284-5200 Fax: 925-284-5204 alex@nltc.com www.nltc.com Dr. S. Alex Stalcup is a graduate of Whittier College and a graduate of the University of California, San Francisco, School of Medicine. He is Board Certified in Pediatrics, and in Addiction Medicine. He is certified as a Medical Review Officer by the American Society of Addiction Medicine (A.S.A.M.). In 1990, after three years as Medical Director Medical Director, Drug Detoxification, Treatment & Aftercare Project, Haight Ashbury Free Clinic in San Francisco, Dr. Stalcup opened a private practice in addiction medicine. Since 1996, he has served as the Medical Director of the New Leaf Treatment Center in Lafayette, California. Dr. Stalcup also serves as a lecturer and consultant for drug treatment and chemical dependency issues to both public and private agencies in California and nationally.

Prescription Drug Abuse Opiate pain medications Benzodiazepine tranquilizers Prescription stimulants (Adderall, Ritalin) Sleeping pills, muscle relaxants According to a web-based survey published in Pharmacotherapy 26(10):1501-1510 2006 College students who illicitly use stimulants (5.9% reported illicit use in the past year, N=269/4580) prefer Adderall=75.8%, Ritalin=24.5%, Modafinil=2.6%, Amphetamine (Benzedrine) 2.4%, methamphetamine=0.8%, other=1.6%. Survey was conducted at a large mid-western university.

Percentage of State and Local Law Enforcement Agencies Reporting CPDs as Their Greatest Drug Threat, 2005-2009

Treatment Admissions / Local and State – Primary Drugs of Abuse Washoe State

Prescription Opiates Generic: Brand Name Non Tolerant 24 hr. dose Codeine w/acetaminophen 500 mg Hydrocodone:Vicodin, Lortab, Norco 20mg-60 mg Hydromorphone: Dilaudid 20 mg-60 mg Oxycodone: Percodan, OxyContin 20 mg-60 mg Morphine sulfate: MS Contin 30 mg-60 mg Fentanyl: Duragesic (transdermal), Actiq 25 mcg-50 mcg Tolerant Users only Tolerant 24 hr. dose Morphine sulfate: MS Contin 60 mg-upward Fentanyl: Duragesic (transdermal) 75 mcg-300 mcg Methadone: Methadose 60 mg-300 mg Buprenorphine: Suboxone, Subutex 6 mg-32 mg

Neuroadaptation, Tolerance, and Withdrawal Neuroadaptation is the brain’s response to over stimulation from drugs. Sedation and stimulation (intoxication) are the result of excessive drug-specific effects on brain functions. Tolerance is the process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure neurotransmitters. In direct response to overstimulation, the brain regions decrease in sensitivity and become unresponsive (deaf) to normal levels of stimulation. In addition to pleasure circuits each drug type affects other brain functions.. Other brain pathways overstimulated by drugs also neuroadapt and become under active, directly leading to anxiety, depression, and loss of energy. Once neuroadaptation develops (tolerance), there will always be Withdrawal symptoms that are the mirror image of the drug effects. Cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless, and lacking energy Under unstimulated conditions (without drugs) there is profound interference with the ability to experience normal pleasure. When sober, the user experiences Craving: anhedonia, anxiety, anger, frustration. The pleasure system remains impaired for months to years, interfering with sobriety, learning, and impulse inhibition.

Definition of Addiction Compulsion: loss of control The user can’t not do it s/he is compelled to use. Compulsion is not rational and is not planned. Continued use despite adverse consequences An addict is a person who uses even though s/he knows it is causing problems. Addiction is staged based on adverse consequences. Craving: daily symptom of the disease The user experiences intense psychological preoccupation with getting and using the drug. Craving is dysphoric, agitating and it feels very bad. Denial/hypofrontality: distortion of cognition caused by craving Under the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using. The natural history of addiction is characterized by progressive loss of control over use, so that the loss of control occurs more readily as the disease progresses. The behavior is compulsive, not voluntary. Therefore, the first characteristic of the disease is loss of control; addiction is a disease of compulsion. Second, the individual with addictive disease continues substance use despite adverse consequences. An addict is someone who uses even though he knows it is causing problems. Despite mounting adverse consequences, the addict continues to use because he is unable to stop, whereas, an individual without addictive disease in the face of problems caused by drug use is able to stop. Craving, the daily symptom of the disease, is defined as intense psychological preoccupation with getting/using the drug. Craving is identical to hunger for food; it is dysphoric, agitating, and feels very bad. Finally, under conditions of craving, the addict’s thinking becomes distorted and the addict behaves in a manner that would not occur but for the drug. Criteria required to diagnose addiction. The main feature of addiction is the inability to NOT use. Addiction hijacks the chemistry of the reward and pleasure system. Addicts do not respond to consequences because they cannot see the consequences under conditions of craving. Note: Denial/hypofrontality: distortion of cognition caused by craving is separate from treatment resistance. Treatment resistance indicates indicates that the addict does not believe that treatment could help him or her.

Causes of Craving in Addicts E W M S Environmental cues (Triggers) immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences Drug Withdrawal inadequately treated or untreated Mental illness symptoms Stress equals craving Craving is defined as the urge to use. All compulsive disorders cause craving and distort executive function (decision-making). Craving distorts thinking. Craving involves active suppression of memory (hypofrontality).

Opiate Effects Analgesia Euphoria Anxiolytic- calming Sleep Inducing Sensation of warmth Constipation Dry mucous membranes Pupils constrict (pinpoint pupils) Sedation/Sleepiness (nodding) Depresses respiration

Physical Dependence Tolerance Physical Dependence Abstinence Syndrome Neuroadaptation forces the user to increase the dose to maintain the effect of the drug. Using an inadequate dose causes withdrawal: symptoms occur when the amount used is less than the tolerance level. Physical Dependence When the user stops the drug, physical illness results. Abstinence Syndrome Name of the illness caused by withdrawal symptoms.

Core Principles in the Use of Opiates for Treatment of Chronic Pain: Detox from all sedative-hypnotic drugs, with meticulous attention to avoid all withdrawal symptoms Substitute all opiates with sustained-release or long-acting opiates: MS Contin, methadone, suboxone Titrate dose to optimum, the dose that relieves pain and relieves pain without sedation Avoid use of "breakthrough" medication

Opiate Withdrawal Pain Dysphoria Anxiety Insomnia Diarrhea Rhinorrhea Chills Pupils dilate Increases heart rate & blood pressure

Kindling Becker HC. Kindling in Alcohol Withdrawal. Alcohol Health and Research World. Vol. 22, No. 1, 1998. P. 28

Overview of Buprenorphine (Suboxone and Subutex) Highly safe medication (acute & chronic dosing). Primary side effects: like other mu agonist opioids (e.g.,nausea, constipation) but may be less severe. No evidence of significant disruption in cognitive or psychomotor performance with buprenorphine maintenance. No evidence of organ damage with chronic dosing. Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds: Strain EC, Trhumble JG, Jara GB) CSAT. 2001 Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds: Strain EC, Trhumble JG, Jara GB) CSAT. 2001

One Year Outcome of Opiate Treatment Overall, the dismal outcome for our controls reiterates the grave nature of heroin dependence, and shows the considerable health and social difficulties faced by our patients. Furthermore, the severity of problems in our patient sample is tragically emphasised by the 20% mortality in the controls over the course of a 1-year study. Kakko J, et.al. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden_ a randomised, placebo-controlled trial. 2003 The Lancet 361 (9358) 662-668

Opiate Progression Pills to the Needle Historically, untreated dependence on prescription opiates led to a trajectory from Pills ingested orally Pills crushed and snorted or smoked Pills injected Heroin snorted or smoked Heroin used intravenously This progression develops over from 12 to 24 months

A 33-year follow-up of narcotics addicts . Hser YI, Hoffman, V, Grella CE, Anglin D. A 33-year follow-up of narcotics addicts. Archives of General Psychiatry. 2001;58:503-508.

Special Problems in Former Opiate Addicts Persons previously addicted to opiates Have low pain tolerance because endogenous analgesic mechanisms are impaired. Will “uncover” their previous level of opiate tolerance over 4 - 6 weeks and require upward dosage titration over an extended time (despite years of abstinence). Require doses 2 to 4 times higher for analgesia than non-tolerant persons (due to high opiate tolerance). Need slower, symptom-driven tapers to discontinue opiates.

C I M Model Treatment Withdrawal Management PRINCIPLES Calculate the dose equivalent per 24 hours Push medications to achieve “symptom capture” Maintain Diastolic BP <90 and Pulse <90 Decrease substitute medication in 10% increments Slow rate of taper to maintain Diastolic BP <90 and Pulse <90 Tremor free SUBSTITUTION TAPER

Withdrawal Management Opiate Oral Dose Equivalents Buprenorphine (Suboxone®) 8 mg (sublingual) Hydrocodone (Vicodin®) 10 - 20 mg Methadone (Methadose®) 20 mg Morphine sulfate (immediate release) 30 mg Morphine sulfate (MS Contin®) 15 mg Oxycodone (Percodan®) (Oxycontin®) 10 - 20 mg Propoxyphene (Darvon®) 130 - 200 mg Adapted from Goodman and Gilman, 9th ed., page 535.

Withdrawal Management Opiate Substitution Query: time since last opiate use Query: all opiates used in past 7 days. Calculate client's usual 24 hour opiate dose. Query: prior withdrawal experience(s). Query: other drugs used: alcohol illicit drugs prescription medications over-the-counter preparations Determine if client requires other detoxification

Withdrawal Management Substitution Methodology Opiates Calculate Suboxone dose using opiate dose equivalents. Give first Suboxone dose (2 - 8 mg) when objective and clear signs of withdrawal are evident. Record Pulse, BP, and withdrawal SX on Symptom Assessment sheet. Recheck Pulse & Blood Pressure after 90 minutes. Give 1/4 of estimated daily Suboxone dose when withdrawal symptoms reappear. Give the remainder of Suboxone in divided doses every 6 - 8 hours.

Withdrawal Management Completion of Substitution Phase Substitution is complete when the patient feels “normal,” and craving goes away. Persistence of insomnia, anxiety, pain, or depression indicate need for separate treatment of these symptoms (dual diagnosis). The patient is now ready for taper or for maintenance.

Withdrawal Management Taper Phase There are two variables in tapering: Dose: how much to taper Time: how often to taper Dose reductions are adjusted so that the patient does not re-enter withdrawal. If withdrawal symptoms develop during taper, return to previous effective dose, reduce amount of taper (dose) or lengthen the (time) interval. Do not continue until symptoms subside. Monitor Pulse and Blood Pressure daily Complete Symptom Assessment sheet daily. Adjust amount decreased and time between decreases to maintain symptom scores at 0-1

C I M Model Treatment Components of Treatment Initiation of Abstinence: Stopping Use Drug Detoxification: Use of medications to control withdrawal symptoms Avoidance Strategies: Measures to protect the client from environmental cues Schedule: Establishing times for arising, mealtimes, and going to bed Mental Health Assessment and Treatment Relapse Prevention Drug Detoxification: Continued use of medications to control withdrawal Avoidance Strategies: Controlled re-entry to cue-rich environments Schedule: Adherence to a regular daily lifestyle HUNGRY Three regularly spaced meals each day ANGRY Separate feelings of anger from losing control of behavior LONELY One positive social contact per day minimum TIRED Daily practice of sleep hygiene Tools: Behaviors that dissipate craving Exercise Spiritual Practice Talk Peer Support Groups Counseling Having Fun Mental Health Treatment

C I M Model Treatment Relapse Prevention Workshop Questions about Craving What is your craving score? What is the cause of your craving? Environmental cue Stress Drug withdrawal Mental health problems What will you do to take care of yourself? Avoidance strategies Stress Management Tools Program activities Principles Addicted persons relapse because of craving. Craving has causes that can be predicted, recognized and analyzed. Craving can be managed with the use of program activities.

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