1. S. Alex Stalcup, M.D. New Leaf Treatment Center
251 Lafayette Circle, Suite 150
Lafayette, CA 94549
Tel:
Fax:
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.

2. 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):
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.

4. Percentage of State and Local Law Enforcement Agencies Reporting CPDs as Their Greatest Drug Threat,

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

6. 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

7. 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.

8. 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.

9. 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).

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

12. 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.

14. 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

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

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

17. 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

18. 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 The Lancet 361 (9358)

19. 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

20. 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:

21. 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 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.

22. 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

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

24. 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

25. 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 hours.

26. 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.

28. 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

29. 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

30. 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.

31. REFERENCES
Benowitz N. Neurobiology of nicotine addiction: implications for smoking cessation treatment. American Journal of Medicine. 121(4A) S3-S10 (2008).
Bechara A. Decision making, impulse control and loss of willpower to resit drugs: a neurocognitive perspective. Nature Neuroscience. 8: (2005)
Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nature Neuroscience. 8(11): (2005).
Nestler EJ, Malenka RC. The addicted brain. Scientific American.com February 9, 2004.
Stalcup SA, Christian D, Stalcup JA, Brown M Galloway GP. A treatment model for craving identification and management. Journal of Psychoactive Drugs. 38:235-44, 2006
Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. Journal of Clinical Investigation. 111(10: (2003).
Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. National Campaign to Prevent Teen Pregnancy. June 2005.