1 Addiction

Addiction Lecture, Dr. Kiame Mahaniah (March 2014)(58 mins)

Definition:

Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spirit manifestations. This is reflected in the individual pursuing reward and/or relief by substance abuse and other behaviors. The addiction is characterized by impairment in behavioral control, craving, inability to consistently abstain, and diminished recognition of significant problems with one’s behaviors and interpersonal relationships. Like other chronic diseases, addiction can involve cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.  (American Society of Addiction Medicine)

Opioids vs Opiates: although often used interchangeably, opiates is officially a more restrictive term, referring only those compounds derived from the natural poppy (morphine, codeine, heroin). Opioids include those opiates, in addition to the semi-synthetic and the synthetic compounds. Practical application: a routine urine drug screen (DSU 9 means it’s checking for 9 compounds) detects opiates well but has very poor negative predictive value for semi-synthetics (hydrodone/vicodin, oxycodone/percocet, hydromorphone, oxymorphone, buprenorphine/suboxone),or full synthetics (dilaudid/fetanyl, methadone, tramadol/ultram).

Dependence means that there is a physiologic requirement for the substance. A lack of this substance induces withdrawl. Dependence is a physiologically normal reaction to taking certain medication frequent enough to constantly have the substance in circulation (not only controlled medications: SSRIs, caffeine, beta blockers, etc.)

Tolerance means that increasing doses of a medication are needed to achieve the same effect. Tolerance is reversible, with the rate depending on the pharmacokinectics of the particular drug, as well as dosage and frequency of use.

Numbers:

• SAMHSA 2007: 1 out of every 200 in US will try illicit drugs any year, 23% will become dependent. Every year, 1 of 800 in US becomes addicted.
• Annually, addiction costs over $500 billion: work loss due to health, illness for users and victims, costs of medical treatment, cost to the justice system, to infrastructure.
• #1 abused substance category: prescribed medication (overtook marijuana 3 years ago, in all categories)
• #1 abused medication in the US: vicodin
• Substance abuse ranks among the top 10 health problems in the United States (NIH 2000)
  • In Massachusetts, addiction claims 2 deaths per day.
  • In 2007, the Merrimack Valley (Lawrence, Lowell, Haverhill, etc…) was ranked as the number 1 heorin dealing area in the country
• Suboxone (buprenorphine) vs Methadone
  • Both valuable treatment options
  • Methadone, for addiction treatment, can only be given in methadone clinics (inpatient stay also if approved by clinic), daily dose, random testing, no ceiling, commonly measured in UDS, large pain control potential.
  • Buprenorphine: can be prescribed by any certified physician (8 hour training course), can be prescribed monthly, needs specialized urine test, blocks all other opioids, medium pain control, has ceiling, little or no euphoria, risk of respiratory depression only if taken with alcohol, benzodiazepine, or sedatives.
  Required Reading:  A Primary Care Approach to Substance Misuse