Opiates Heroin/Prescription. Steve Hanson Director of Treatment NYSOASAS

Opiates

Heroin/Prescription

Steve Hanson

Director of Treatment NYSOASAS

Opiates

• Dates to 4,000 BC

• Mimics endorphin activity

• Natural - Opium, morphine, codeine • Semi-synthetic- Heroin, Dilaudid

Modern History

• Off and on use through until the 60’s • “Man with the Golden Arm”

• Vietnam war – soldiers using heroin

• 1970’s – increased prevalence – urban areas • Treatment programs – Methadone Maintenance

/ Therapeutic Communities

• 1980’s Hard to find – substitutes • 1990’s – resurgence

“Take the best orgasm you’ve ever had…

Multiply it by a thousand. And you’re still nowhere near it.

Opiates

• Heroin more potent -60-80% - <10% in ‘70’s

• Younger age group - High School

• Users start with snorting - IV within 12 months

NATURAL OPIATES

Morphine

Codeine

Thebaine

OPIUM

Semi-synthetics

Heroin

Dilaudid

Morphine

Synthetics

• Demerol • Fentanyl

• Methadone • Darvon

Opiates

• Fat solubility – Heroin – high – rush • Morphine – lower – longer onset

• Heroin metabolized into morphine • Morphine metabolized by the liver • Metabolite is 10-20X more powerful • Detectable in urine for 2-4 days

The Action of

Heroin

Tolerance

• Rapid tolerance with continued use • Initial dose of 50mg/day can go to

500mg/day in as little as 10 days

• Cell sensitivity thought to be the tolerance mechanism.

Addiction/Dependency

• Opioids trigger reward system – euphoria – leads to continued use – addiction

• Withdrawal symptoms are significant – regular use to avoid withdrawal -

Opiate Effects

• Analgesia - change in pain perception • Euphoria - whole body orgasm

• Sedation - “on the nod”

• Respiratory Depression - OD • Cough Suppression

• Nausea/vomiting • Constipation

Withdrawal

• Pain • Depression • Alert • Rapid Breathing • Coughing • Nausea/Vomiting • Diarrhea • 3-5 days

Overdose Reversal Kits

• Kits can save lives

• Train First Responders, families, treatment staff, and…PARTICIPANTS

Potency Factors by Weight

• Morphine 1 • Heroin 3 • Codeine 0.1 • Dilaudid 8 • Demerol 0.05 • Fentanyl 300 - 1000

Heroin usage patterns

• Highly addictive and dependence producing

• Significant tolerance up to 35X • Increased cost

• Tolerance management (Tx, jail, etc.)

• Mixing with other opiates and other drugs (speedballing/cocaine)

Treatment

• Traditional Recovery Based/NA • Naltrexone - Antagonist/Blocker

• Opiate Maintenance Tx – withdrawal management

– Methadone- daily

– Buprenorphine/Suboxone

Nonmedical Use of Prescription

Drugs, Ages 12+: 2002-2005

Percent Using in Past Month

1.9 0.5 2.7 0.8 1.8 0.5 0.1 0.8 0.2+ 2.6 0.1 2.0 0.5 0.7 2.5 0.7 0.1 2.6 1.9 0.4 0 1 1 2 2 3 3 Any Psycho-therapeutics

Pain Relievers Stimulants Sedatives Tranquilizers

2002 2003 2004 2005

Two “Types” of Rx Drug Abusers

• The Drug Abuser who likes Rx drugs.

– Frequently use other drugs (cocaine,

alcohol, heroin, other non-Rx drugs)

– Fits the “model” of a drug abuser.

– “addicted” to high

• The Patient who

becomes dependent on their medication

– Infrequent use of other substances – unless can’t get Rx.

– Don’t fit “model” of

drug user – age, other behaviors.

– “dependent” on the drug

Addiction vs. Dependency

• Addiction – use the drug for the high, euphoria

• Dependent – use the drug to avoid unpleasurable withdrawal effects • Can be both

Nonmedical Use of Pain Relievers in Past Year among Persons

Aged 12 or Older, by Substate Region: Percentages, Annual Averages Based on 2002-2004

The Action of

Opiates

Tolerance

• Rapid tolerance with continued use

• Cell sensitivity thought to be the tolerance mechanism.

• User now needs to find additional amounts • Multiple doctors

Oxycontin

• Oxycodone – synthesized from thebaine (part of opium)

• Oxycontin – 1995

– Crush the tablet for quicker high – Oral, snort, inject

• Percocet – oxycodone & acetominophen • Percodan – oxycodone & aspirin

Vicodin

• Hydrocodone and acetominophen • Lorcet, Lortab

• Schedule III – high psychological/medium physical

Issues with Rx Opiate Dependence

• Presence of real pain

• “I’m addicted to vicodin, not alcohol, why do I have to quit that too?”

• Drug Testing – make sure you test for drug of choice as well as alternatives.

Why Prescription Drug Users May

Believe That They Are “Different”

• “I had/have real pain, I wasn’t using these to get high like those drug addicts”

• “My doctor prescribed these for me. It wasn’t my idea”

• “I never robbed anyone or did those things that addicts do.”

What the Rx Drug User Might Have

Trouble Relating To

• “Hitting Bottom”

• Changing People, Places & Things • Change your “Lifestyle”

• You must be completely abstinent from everything else – alcohol included

Drug Court/Treatment Issues

• Urine testing – ensuring that the panel used includes the drugs that the

participants take

• Medication needs – people suffering from a medical/psychiatric condition that needs to be medicated – which medications are “okay”

Medication

Assisted

Therapy

& Drug Courts

Is Addiction a Brain Disease?

Neuroimaging demonstrates drug/alcohol addiction alters brain structure & function. Similar to disease processes of

mental illness & physical trauma.

SPECT images from Amen 2001

National Institute of Drug Abuse

12. Medications are an important part of

treatment for many

drug abusing offenders.

Medicines such as methadone and

buprenorphine for heroin addiction have been

shown to help normalize brain function and should be made available to

individuals who could benefit from them.

“…NADCP unequivocally supports patient access to opioid replacement therapy, of which methadone is a form, when medically appropriate.

Similarly, NADCP opposes attempts, no matter how well-meaning, to interfere with or otherwise

undermine considered clinical judgments regarding proper treatment protocols arrived at by qualified

treatment professionals overseeing the care of drug court participants.”

- Letter from West Huddleston to Judge Tynan (CA) 7/29/09

Does Treatment Work?

Medications + psychosocial therapy both benefit brain function and recovery. Each affects different parts of brain and in opposite ways.

Goals of Drug Courts

Break cycle of addiction

Stop/reduce criminal behavior Enhance Public Safety

Cost efficient method of dealing with addiction and crime

Challenges to Success

Relapse Craving

The drugs work

Pharmacological Interventions

Goals

1. To provide relief from withdrawal

symptoms

2. To prevent drugs from working

3. To reduce craving

4. To provide aversive reactions

These actions are helpful in reducing relapse and increasing retention in programs

AMYGDALAR CONNECTIVITY during brief .5 sec Cocaine Cues

Drug 2 amyg conx (n=7)

Placebo

Baclofen

Source: Childress, et al, unpublished

Opiate Replacement Approaches

23.4% of state prisoners have history of heroin/opiate abuse - ONDCP, 2007

Methadone –reduces craving, mediates

withdrawal symptoms, helps restore normal brain functioning

Buprenorphine/Suboxone – similar purpose

to methadone, may be prescribed by an MD with special training)

Opiate Replacement Treatment

Courts/Providers reluctant to use

– Substituting one addiction for another – Not “real” recovery

– Concerns about programs, other drugs, etc.

ORT Substitutes One Addictive Drug

With Another?

ORT uses medication (methadone/Suboxone) to overcome craving and need for illicit

opioids.

ORT pharmacologic actions differ

from other opioids; not mere substitute.

– Orally effective, long acting, cross tolerance (blockade)

Addictive, opioid-seeking, behaviors cease. ORT benefits overshadow reliance on

dependency-producing medication.

Consequences of untreated opioid addiction include: destitution, prison, disease, and/or early death.

MMT Patients Get “High”?

At appropriate and adequate stable doses, normal function – no lasting euphoria or sedation.

Adequate methadone dose avoids

extremes of intoxication or withdrawal. After dosing, some patients may

“sense” onset of methadone effects or have vague feelings of “well-being”

Taming the Roller Coaster

Adequate methadone smooths peaks & valleys – shifting from opioid

intoxication to withdrawal. Patients can live more comfortably normal lives throughout each day.

ORT Patients Abuse Other Drugs?

ORT not a “cure” for addiction.

– Addresses illicit opioid withdrawal and craving.

Pharmacologically little effect on alcohol, cocaine, etc.

With adequate ORT,

most patients do eliminate or reduce other drug abuse.

Ongoing counseling, psychosocial treatment, needed services and self help groups are

Benefits to Drug Court

Like other Chronic illnesses, a variety of treatment options are needed

Evidence showing decrease in use of non-prescribed substances

Decreased Criminal activity

Drug Court provides support and structure that improve compliance and outcomes

Patient Needs

Diabetes

Some can control with diet

Some can control with medication

Some are insulin dependent

Without adequate

treatment - many will die

Opiod Addicts

Some can quit on own

Some can remain abstinent with

“regular” treatment Some need ORT Without adequate

treatment - many will die

Benefits to Drug Court

It can save lives!

The treatment does work with

Drug Court

Fairfield County, Ohio

–62% grad rate with Suboxone

–13% grad rate without

Methadone Effectiveness

Gunne & Gronbladh, 1984

H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H H

Methadone Regular Outpatient Rx. Baseline

Methadone Effectiveness

Gunne & Gronbladh, 1984

After 2 Years

1- Sepsis & endocarditis 2- Leg amputation 3- Sepsis P H H H H P P H H H H H H H H H H H H Methadone No Methadone 1 3 2 D D

Methadone Effectiveness

Gunne & Gronbladh, 1984

P H H H P Methadone No Methadone After 5 Years P P D D D D D

Binswanger IA et al. N Engl J Med 2007;356:157-165

RR=12

RR=4 RR=3.2

Release from Prison - A High Risk of

Death for Former Inmates

Binswanger IA et al. N Engl J Med 2007;356:157-165

Causes of Death among Former

Inmates

Adjusted for Age, Sex, and Race

0 2 4 6 8 10 12 Over dose Hom icide Live r Dise ase _MVA Suici de CVD Canc er R el ati ve R is k o f D ea th