Martina Smit, MD Theresa Lo Sept 18, 2015 Addiction Psychiatry Martina Smit, MD Theresa Lo Sept 18, 2015

Objectives Overview of addiction: Assessment neurobiology DSM5 criteria for substance use disorders specific substance syndromes Assessment Substance use history Treatment options, resources

Addiction: A primary, chronic disease of Brain reward Motivation Memory, and related circuitry American Society of Addiction Medicine

REWARD CIRCUITRY Associative learning  High significance to substance, Substance-rel’d cues Marks salience of reward Signals rewarding event Will occur http://neurowiki2012.wikispaces.com/file/view/Reward_circuit.jpg/315908202/Reward_circuit.jpg

Neurotransmitters and Effects Dynorphin: dysphoria  Dopamine: dysphoria  CRF: stress  Serotonin: dysphoria  Norepinephrine: stress  GABA: anxiety, panic attacks  Glutamate: hyperexcitability  Opioid peptide: dysphoria Koob GF, Simon EJ. The Neurobiology of Addiction: Where We Have Been and Where We Are Going. Journal of drug issues. 2009;39(1):115-132.

Substance-related and addictive disorders General diagnostic criteria Substance-related and addictive disorders

DSM5 Substance Use disorder 2 or more in 12 months: Larger amts/longer period than intended Persistent desire/unsuccessful efforts to cut down A great deal of time spent to obtain, use, recover Craving Recurrent use  fail to fulfill major role obligations Continued use despite problems due to substance Important activities given up or reduced Recurrent use in physically hazardous situations Continue use despite knowledge of phys or psychol problems Tolerance withdrawal

Severity Mild: 2-3 symptoms Moderate: 4-5 symptoms Severe: 6+ symptoms

Physiologic dependence Tolerance Withdrawal need more for same effect; or, less effect with same amount characteristic syndrome; Or, take same or similar substance to avoid it

Specific substance syndromes

Alcohol intoxication Slurred speech Dizziness Incoordination Unsteady gait Nystagmus Impairment in attention or memory Stupor or coma - Many receptors involved

Alcohol: low risk use Men <65yo Women <65yo Special occasions: No more than 3 drinks/day AND No more than 15 drinks/week Women <65yo No more than 2 drinks/day AND No more than 10 drinks/week Special occasions: No more than 4 drinks at a time for men No more than 3 drinks at a time for women

Alcohol withdrawal: (2 or more) Autonomic hyperactivity Increased hand tremor Insomnia Nausea or vomiting Transient hallucinations (visual, tactile, auditory) Psychomotor agitation Anxiety Grand mal seizures Delirium tremens Tremulousness: 6-8 hours Hallucinosis: 8-12 hours Seizures: 12-24 hours DTS: anytime during the first 72 hours and can be within 1st week

Alcohol withdrawal mgmt Inpt vs outpt Benzos Fixed-dose vs symptom-triggered (CIWA) Thiamine IM, multivitamins Investigations? CBC, Lytes incl K, Mg, LFTs, INR, BAL Inpatient: GI bleed, electrolyte abN, infxn, unstable CVD, pregnancy, SI, psychosis, significant cognitive impairment

Cannabis intoxication Behavioral or psychological changes Lower doses: Relaxation, euphoria, altered time/sensory perception; Higher doses: Hypervigilance/paranoia; anxiety/panic; derealization/depersonalization; hallucinations 2 or more of: Conjunctival injection, increased appetite, dry mouth, tachycardia ***chronic THC use in youth associated with psychosis/schizophrenia -acts on cannabinoid receptors (found throughout CNS)

Cannabis withdrawal 3 or more: Irritability, anger or aggression Nervousness or anxiety Sleep difficulty (insomnia, disturbing dreams) Decreased appetite or wt loss Restlessness Depressed mood At least 1 phys sx: abdo pain, tremors, sweats, fever, chills, HA

Stimulant intoxication 2 or more Tachycardia or bradycardia Pupillary dilation Elevated or lowered BP Perspiration or chills Nausea or vomiting Wt loss Psychomotor agitation or retardation Muscle weakness, respiratory depression, chest pain, arrhythmias Confusion, seizures, dyskinesias, dystonias, or coma Mechanism: cocaine: Monoamine reuptake inhib; Amphet: MAO inhib, DA+NE release

Stimulant Withdrawal “Crashing” Dysphoria 2 or more of Fatigue Vivid, unpleasant dreams Insomnia or hypersomnia Increased appetite Psychomotor retardation or agitation

Opioid intoxication Pupillary constriction (or dilation due to anoxia in severe OD) AND Drowsiness or coma Slurred speech Impairment in attention or memory ***OD  life-threatening respiratory depression

Opioid withdrawal Anorexia Anxiety Craving Dysphoria Fatigue Headache Burgeois J et al Eds 2012 Early to Moderate Moderate to Advanced Anorexia Anxiety Craving Dysphoria Fatigue Headache Irritabilityacrimation Mydriasis (mild) Perspiration Piloerection “cold turkey” Restlessness Rhinorrhea Yawning Abdo cramps Broken sleep Hot/cold flashes Incr BP Low-grade fever Muscle/bone pain Muscle spasm “kick the habit” Mydriasis Nausea, vomiting

Sedative-Hypnotics Barbiturates Benzos Z-drugs (zopiclone) Lethal in OD Benzos Bind to bzd receptors, enhance GABA Z-drugs (zopiclone) Intoxication and withdrawal similar to alcohol Benzo intoxication: slurred speech, ataxia, altered LOC Benzo withdrawal (can be life threatening): tremors, anxiety, perceptual disturbances, dysphoria, psychosis, seizures

Hallucinogens (LSD, others) LSD interferes with serotonin neurotransporters Psilocybin, mescaline, [mdma] Intoxication (2 or more): Pupillary dilation blurred vision Tachycardia tremors Sweating incoordination palpitations Behavioural / psychological changes: marked anxiety or depression, ideas of reference, fear of losing one’s mind, paranoid ideation, impaired judgement

PCP, ketamine Antagonize NMDA glutamate receptors Intoxication (2 or more): VERTICAL or horizontal nystagmus HTN or tachycardia Numbness, diminished responsiveness to pain Ataxia Dysarthria Muscle rigidity Seizures or coma hyperacusis Behavioural changes: belligerence, assaultiveness, impulsiveness, unpredictability, psychomotor agitation, impaired judgement

Inhalant intoxication (2 +) Dizziness Nystagmus Incoordination Slurred speech Unsteady gait Lethargy Depressed reflexes Psychomotor slowing Tremor Generalised muscle weakness Blurred vision or diplopia Stupor or coma euphoria CNS depressant Common: gasoline, glue, spray paint, solvents, cleaning fluids, other aerosols Pharmacodynamics not well understood Behaviour: apathy, diminished social and occupational functioning, impaired judgement, and impulsive or aggressive behaviour Recent user: rashes around patient’s nose and mouth, unusual breath odours, residue on face, hands, clothing; irritation of eyes, throat, lungs, nose

A 43yo F is brought to ER after becoming aggressive with a police officer during a routine traffic stop. She is noted to be extremely argumentative, with a labile mood. She makes several sexually inappropriate remarks to the examining physician. Examination reveals an unsteady gait, slurred speech, nystagmus and flushed face. The patient is afebrile, HR 78, respiratory rate 24/min. This pt’s presentation is most consistent with acute intoxication from which of the following? Alcohol Cannabis Cocaine Hallucinogens Opioids Focus 2011

A 32yo M is brought to the ER after sustaining a generalised tonic-clonic seizure. Pt it noted to be hypervigilant and extremely abusive and aggressive. He suspects that the technicians may be taking blood samples from him for illegal purposes. He complains of nausea. Past medical hx is unremarkable and the pt is currently taking no meds. Examination reveals pt to be diaphoretic. He is afebrile, pulse 124, respirations 28 and BP 164/96. Pupils are dilated, but reactive to light. The pt’s presentation is best explained by acute intoxication from which of the following? Alcohol Cannabis Cocaine Heroin Phencyclidine Focus 2011

Assessment

Screening All pts presenting for substance use treatment should be screened for co-occuring MH disorders All pts presenting for MH treatment should be screened for co-occurring substance use disorders

CAGE Questionnaire Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? Scoring: Item responses on the CAGE are scored 0 or 1, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. Copyright: © American Psychiatric Association

Substance Use HX: TRAPPED Treatment History (detoxification, treatment programs, medications, 12-step programs) Route of administration (smoked, orally ingested, snorted, inhaled/"huffed," injected IV/IM/SC) Amount (money spent, "pills," "bags," "vials," grams, ounces per bottle, frequency) Pattern of use (binge, daily, solitary, period of heaviest use, etc.) Prior abstinence (duration, what has helped in past, both in and out of a controlled environment) Effects (direct and indirect, adverse, physical, social, legal, positive, withdrawal,etc.) Duration of use (age of first use, most recent use) Welsh CJ. Academic Psychiatry 2003:27:289

Stages of change Prochaska & DiClemente 1992

Physical Exam http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/drug-abuse-and-addiction/Default.htm

Meds Treatment

Alcohol Naltrexone Acamprosate Disulfiram Possibly (some evidence): topiramate, baclofen Naltrexone: blocks opioid receptors -> reduced craving, reduced reward in response to drinking Acamprosate: affects glutamate and GABA neurotransmitter systems (?EtOH effect) Disulfuram: inhibits intermediate metabolism of alcohol Topiramate: antagonizes glutamate, facilitates GABA Baclofen: GABA agonist

Opioids Methadone Buprenorphine Symtomatic trx (e.g. Clonidine, ibuprofen, tylenol, lorazepam, phenergan, imodium) Clonidine: alpha 2 agonist with sympatholytic properties (net effect is to decrease NE) Phenergan: for postnarcotic nausea

Nicotine NRT (gum, patch, inhaler, spray) Bupropion Varenicline

42yo F is started on a medication for alcohol dependence 42yo F is started on a medication for alcohol dependence. At a party, she decides to have one drink. Shortly thereafter, she becomes nauseated, tachycardic, and hypertensive with marked facial flushing. The medication was most likely: A. Acamprosate B. Naltrexone C. Disulfiram D. Naloxone

Psychosocial Treatment

Psychosocial CBT Motivational enhancement 12-step Interpersonal therapy Family/group/marital Self-help Case management

Treatment settings Outpatient Day programs Residential Recovery houses…

A patient with alcohol dependence is referred for substance treatment by his family practitioner. The patient is not sure his drinking is that problematic. Which of the following would be the best initial approach? A. motivational interviewing B. CBT C. Psychodynamic psychotherapy D. Supportive psychotherapy E. 12-step program Focus 2011

A 45yo Caucasian single M mechanical engineer has a two-year history of depression and 20 years of problematic alcohol consumption. He has found 12-step programs partially helpful for his drinking, but is now motivated to receive a professional, integrated approach to managing both his depression and drinking. He has researched treatment options and would like to try a course of CBT and medication. Which one of the following is the best medication approach to address his depressive sx and addictive behavior? Lorazepam only Naltrexone and sertraline Naltrexone only Sertraline and lorazepam Sertraline only Focus 2011