Medical Treatments for Substance Use Disorders

Shonali Saha, MDAdolescent and Young Adult Addictionologist

Whole and Health Youth, LLC (wholeandhealthyyouth.com)Attending at Ridgeview Institute

Adjunct Associate Professor in Internal Medicine and PediatricsEmory School of Medicine

Adjunct Associate Professor in Pediatrics Morehouse School of Medicine

Georgia School of Addiction Studies

Savannah, GA

August 25, 2015

Disclosure:

I have no financial disclosures or conflicts of interest.

I will discuss new products in development, not yet approved by FDA.

  

Whole and Healthy Youth, LLCYoung Adult and Adolescent specialistSmyrna, GA outside of AtlantaBoard Certified Internist and Addictionologist

Completed fellowship in Young Adult and Adolescent Medicine at Johns Hopkins

Certified Yoga Instructor

 Shonali Saha, MD

Learning ObjectivesTo discuss cases where medications have been used as adjunct therapies to support sobriety

To summarize the current literature on medication treatments for substance use disorders

To recognize risks and benefits of commonly used addiction treatment medications

To explore new medical treatments being studied for addiction

Disclaimer:

Source: NIST, National Institute of Standards and Technology

Case 154 year old man with a history of depression and severe alcohol use disorder presents to your office smelling of alcohol several weeks after leaving detox.After you take his keys, what is the most appropriate step in his care?

Who will you call?

Your thoughts?

Alcohol Detoxification Protocols Benzodiazepine taper is standard of care for alcohol detoxification.

Preferably long acting (chlordiazepoxide, diazepam)

For elderly patients, those who have severe liver impairment, or COPD, short acting benzodiazepines prevent oversedation

(Safe to give a LOT-Lorazepam, Oxazepam, and Tenezepam)

Rapid onset benzodiazepines for patients who are seizing or delirious (The LAD was too glad-Lorazepam Alprazolam, and Diazepam)

Barbituates-less expensive and reduces withdrawal symptoms BUT greater risk for oversedation, no decrease in seizure or delirium

The ASAM Principles of Addiction Medicine, 5th Edition, 2014, p.643

Adjunct Medications for Alcohol Detoxification

Thiamine: prevent Wernicke’s and Korsakoff’s*If giving glucose to alcohol dependent pt->always give thiamine first as glucose will deplete B vitamin reserves

Folate and MVI: usually depleted in heavy alcohol use Magnesium: may be falsely elevated at admission; ?seizure

prevention Phosphorus: may be falsely elevated at admission; prevent

refeeding syndrome B-Blockers and alpha adrenergic agonists: for ANS

symptoms Anti-convulsants (Carbamazepine, Gabapentin) Anti-psychotics: Be cautious; Can improve AMS but may

lower the seizure threshold

The ASAM Principles of Addiction Medicine, 5th Edition, 2014, p.644-6

Case 1 continued…Your patient returns 6 months later saying he relapsed. He has been drinking daily and having to start in the morning. His wife is concerned that she saw him seizing in bed last night. He was too scared to drink anything this morning upon hearing that.

Case 1 continued…He knows he has to detox, but he doesn’t want to go to an inpatient facility.

He wants you to refer him to a doctor that with detox him as an outpatient.

He is sweating and tremulous. He is starting to not make sense, but doesn’t smell of alcohol this time.Now, who will you call?

Seizure Risk and Delirium Tremens in Alcohol Withdrawal

Greatest risk for grand mal seizure between 8-24 hours after last drink

Withdrawal seizure risk estimated to be between 11-33% (Victor & Adams, 1953; Isbell et al, 1955; Saitz et al, 1994; Wetterling et al,2006)

15% of status epilepticus due to alcohol withdrawal (Alldredge & Lowenstein, 1993)

DTs can present within 3-4 days of last drink DT risk varies depending on patient (acuteness of medical

comorbidity, age, days since last drink, SES, nutritional status) (Ferguson et al, 1996)

Exclusion Criteria for Ambulatory Detox

Co-occurring acute or chronic medical or psychiatric illness requiring inpatient hospitalization

Chronic, severe medical problems (severe or end stage liver disease, heart disease, epilepsy)

Pregnancy History of seizure or delirium tremens during previous alcohol

detoxification Active severe alcohol withdrawal syndrome Delirium Unable to follow up Unstably housed or homeless Presents alone Active abuse of other substances, especially opiates or

benzodiazepines Adapted from: Blondell RD. Ambulatory detoxification of patients with alcohol dependence. American Family Physician. 2005;71(3):495

Case 2A 34 year old woman with anxiety states she is having increased cravings to drink after 3 weeks of sobriety. She has been making meetings daily, but lately she has been driving by liquor stores on the way home. What medications may support her in the

recovery process? What medications do you tell her to avoid

for her anxiety?

Who is an “alcoholic”?Diagnosis of SUDs in the DSM V Using larger amounts or for longer than meant to Failure to cut back Spending a lot of time getting, using, or recovering from use Cravings Failure to fulfill major role obligations at work, school, or home Continuing to use, despite relationships problems Important social, occupational, or recreational activities may be

given up or reduced because of substance use Recurrent substance use in situations in which it is physically

hazardous Continued use despite knowledge of having a persistent or

recurrent physical or psychological problem that is likely to have been caused or exacerbated by use

Tolerance Withdrawal

(2-3)=Mild (4-5)=Moderate (6+)=Severe

Prevalence of Alcohol Use Disorders (AUDs) in the United States

~17 million (7.2%) adults had an AUD in 2012->11.2 million men (9.9%) and 5.7 million women (4.6 %)

~88,000 people die from alcohol related causes annually

3rd leading preventable cause of death~1.4 million (8.4% in need) adults received

treatment for an AUD at a specialized facility in 2012->416,000 women (7.3% of women in need) and 1.0 million men (8.9 % of men in need)

http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics

We need you!

Just as there are not enough for all the diabetics in this country->there not enough addiction counselors to care for those with addictive disorders

We must all and do play a vital role!

Medication Mechanism

Medications for Alcohol Use Disorders approved by FDA

Disulfuram (oral pill)

Naltrexone (oral pill and IM depot injection)

Acamprosate (oral pill)

Inhibits breakdown of alcohol causing severe reaction (flushing, nausea, palpitations) due to build up of aldehyde

Blocks opiate receptor: decreases cravings and inhibits positive reinforcement; no “buzz”

Mechanism uncertain; glutamate mediated; helps in prolonged withdrawal

Case 321 year old woman presents in your office for initial evaluation for depression. During the substance use history, she reports being addicted to prescription pain pills.What advice might you give her today about her

mental health?How common is this case?What do you do if this patient overdoses in your

waiting room waiting to see you?

cdc.gov

“The Changing Face of Heroin in the United States”

Title Reference: Cicero et al, 2014

Responsible Prescribing of Controlled Substances

Treatment plans: incorporate functional goals Informed consent Prescribing agreements Periodic review Monitoring with routine urine toxicology Referral for patient requiring high doses Patient education on safe use, storage, and

disposal of opioid medication Termination strategies for chronic opioid

therapy

FSMB Responsible Opioid Prescribing: A Clinician's Guide available at http://library.fsmb.org/book/

Georgia Prescription Drug Monitoring System www.hidinc.com/gapdmp

Medication Mechanism

Medications for Severe Opiate Use Dx

Methadone

(tablet dissolved in liquid)

Buprenorphine or Buprenorphine/Naloxone (sublingual tablet, sublingual film, buccal film)

Naltrexone (oral and IM depo)

Full opiate agonist; can only be prescribed in program with waiver

Partial opiate agonist; effective office based therapy but prescriber needs DEA waiver; paired with Naloxone to prevent diversion

Blocks opiate receptor: protects against overdose; IM may prevent cravings

Drug Addiction Treatment Act

“DATA Waiver” of 2000

The Recovery Enhancement for Addiction Treatment TREAT Act in US Senate

Changing the Controlled Substances Act: Me and my “X”

Special DEA Waiver for MD Rx for buprenorphine

30 pts the 1st year 100 pts after

Special DEA Waiver for MDs, PAs, and NPs

100 pts the 1st year unlimited pts for specialists

and those in “qualified practice settings”

senate.gov

Signs of Opiate Use on Physical Exam

Overdose Protection with Naloxone

Community members (nonmedical, including users’ families) taught to administer intranasal Naloxone and shown to have decrease in overdose rates as compared to communities that did not have training (Walley et al, 2013)

Intranasal Naloxone reverses overdose 82% of cases; same median time to response as IM (Kerr et al, 2009)

As of April 2014, 3rd parties may administer naloxone without penalty in Georgia

prescribetoprevent.org

Case 4A 15 year old male brought to you after his parents discover marijuana in his closet. They are former patients and both recovering alcoholics. They are worried he is going to be an addict.

Case 4When interviewing the youth alone he tells you that “It’s a plant, and it’s natural. And they just made it legal in Georgia. What is the problem?”What is your reply?

Preparing for discussions about Marijuana with your patientsKnow the factsHave a scriptResource: Volkow et al. Adverse Health Effects of Marijuana Use, NEJM, June 5, 2014

Medical Conditions proposed for cannabis oil use in Georgia (Haleigh’s Hope Act-passed)

CancerMultiple SclerosisSeizure disordersAmyotrophic lateral sclerosis (ALS)Crohn’s diseaseParkinson’s diseaseMitochondrial diseaseSickle cell disease

http://www.legis.ga.gov/Legislation/en-US/display/20152016/HB/1

Getting the team together…How do you get a doctor to talk to you?

What is your role on the team?What is your obligation to the patient?

Injections, Implants, and Vaccines:Addiction Medicine of the Future

Medications for Marijuana Use DisordersCocaine vaccineBuprenorphine injections (1m)Naltrexone and Buprenorphine implants

(3m-6m)

http://www.deamuseum.org/ccp/coca/effects.html

Thanks to all of you and GSAS!

  

Accepting new patients 12 and upMost insurances including Medicaid Located in Smyrna, GA on campus of Ridgeview Institute 

Office number: 770-431-2354More info at wholeandhealthyyouth.com

 Shonali Saha, MD