understanding drug abuse and addiction · •gaba –lowers anxiety •endorphins –pain relief,...
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Understanding Drug Abuse and Addiction
Steve Hanson - Associate Commissioner
NYS OASAS
Basic Questions
•Why do people do drugs?
•Why can’t/ won’t some people stop?
Realities
1. People like Drugs.
2. We all like things faster and easier.
Drive to Get High
Some people will seek any means to alter their state of consciousness
Bio-psycho-social model
BIO PSYCHO
SOCIALInteraction
Neurotransmitter Action
ReuptakeRelease of NT
Receptor
How Drugs Work
• Interact with neurochemistry
•Results:•Feel Good – Euphoria/reward•Feel Better – reduce negative feelings
Addiction is a Brain Disease
Prolonged Use Changes
the brain in Fundamental
and Long Lasting Ways
Brain Changes
methamphetaminemarijuanaecstasyopiumetc.
Food
0
50
100
150
200
0 60 120 180
Time (min)
% o
f B
asal
DA
Ou
tpu
t
NAc shell
Empty
Box Feeding
Source: Di Chiara et al.
FOOD
Sex
100
150
200
DA
Co
nce
ntr
atio
n (
% B
ase
line
)
MountsIntromissionsEjaculations
15
0
5
10
Co
pu
lation
Frequ
ency
SampleNumber
1 2 3 4 5 6 7 8 9 101112131415 1617
ScrScrBasFemale 1 Present
ScrFemale 2 Present
Scr
Source: Fiorino and Phillips
SEX
Nicotine
0
100
150
200
250
0 1 2 3 hr
Time After Nicotine
% o
f B
asal
Rel
ease Accumbens
Caudate
NICOTINE
Alcohol
100
150
200
250
0 1 2 3 4hr
Time After Ethanol
% o
f B
asal
Rel
ease
0.250.51
2.5
Accumbens
0
Dose (g/kg ip)
Alcohol
0
100
200
300
400
0 1 2 3 4 5 hrTime After Cocaine
% o
f B
as
al R
ele
as
e
DADOPACHVA
AccumbensCOCAINE
Cocaine
0
100
150
200
250
0 1 2 3 4 5hr
Time After Morphine
% o
f B
as
al R
ele
as
e
Accumbens
0.5
1.0
2.5
10
Dose (mg/kg)
MORPHINE
Source: Di Chiara and Imperato
Heroin
Morphine
Source: Di Chiara and Imperato
0
100
200
300
400
500
600
700
800
900
1000
1100
0 1 2 3 4 5 hr
Time After Amphetamine
% o
f B
as
al R
ele
as
e DA
DOPAC
HVA
AccumbensMETHAMPHETAMINE
Methamphetamine
Behavior Pathways•Rewarding behaviors can become routine
• “Subconscious” control of the behavior
•Difficult to extinguish behaviors because people are not always aware when they are initiated.
•Resistant to change
Circuits Involved In Drug Abuse and Addiction
GOSTOP
Go & Stop
• Craving elicits Go!!
• Powerful
• Activity in limbic system not frontal cortex
• Feeling/reacting vs. thinking/planning
• Thinking initiates Stop!!
• Addicts have “bad brakes” – Stop!
• Hard to stop this fast moving car.
Nature Video Cocaine Video
Front of Brain
Back of Brain
Amygdala
not lit upAmygdala
activated
Craving and the Male Brain
AMYGDALAR CONNECTIVITY
during brief .5 sec Cocaine Cues
Drug 2
amyg
conx (n=7)
Placebo
Baclofen
Source: Childress, et al,
Baclofen blunts AMYGDALAR CONNECTIVITY
Chemical Dependency
•Chronic Disease Prone to Relapse
•Requires significant behavior changes
•Similar to Heart Disease, Diabetes, Asthma, Gingivitis,etc.
•Similar treatment “success”
Drug Types
• Stimulants: Cocaine, Caffeine, Methamphetamine
• Depressants: Alcohol, Barbiturates, Anti-Anxietals
• Pain Relief: Opioids, Aspirin, Ibuprofen
• Hallucinogens: LSD, Ecstasy, Bath Salts
• Cannibinoids: Marijuana, Synthetics
Cocaine
•Natural Stimulant from South America
•Main Effects:• Euphoria
• Fight/Flight
• Snorted, Smoked, Injected, Other Mucosal Absorption
Snorted - onset 2 mins.
Smoked - onset 5-12 seconds30-40 mins
1 hour15 mins
5 mins
Dose Response
DOSE
EFFE
CTS
Euphoria
Psychosis
Paranoia
AnxietyEnergized
MetabolicCrisis
Animal Studies• Primates will ignore food and water in order to get
cocaine – to the point of death by starvation/dehydration
• Given unlimited access to cocaine, animals will quickly die from cocaine related deaths.
Stopping Cocaine Use
•Anhedonia - Dopamine depletion
•Craving - intense craving for drug
Methamphetamine
• Synthetic stimulant – Amphetamine family
• Main Effects 8-12 hours from single dose:• Euphoria
• Energy
• Snorted, smoked, injected
Methamphetamine
DOPAMINE DOPAMINE
Meth - Signs of Abuse
•Rapid weight loss•Nervous energy•No “need” for sleep•Aggressive• Excited talk• “Meth mouth”
Meth - Signs of Withdrawal
• long crash•apathy•depression• fatigue
•anxiety•suicidal ideation•cravings
Alcohol•Most popular drug of abuse•Probably the most physically toxic of
drugs •Damages almost every organ in the body• Easy access, adults use, advertising,
relatively inexpensive.• THE DRUG for Youth
Action
•Dopamine – excitement & reward
•Serotonin – feel – “normal”
•GABA – lowers anxiety
•Endorphins – pain relief, reward, craving
Benzodiazepine Family
• Anti-Anxiety: Valium, Xanax
• Sleeping Aids: Ambien, Lunesta
• Can produce dependency
• Long withdrawal periods.
Opioids
Source: CDC
Drug Poisoning Deaths Involving Opioids: USA, 2000-2013
Source: CDC
Opioids
Natural Opiates
Derived from raw opium
• Morphine
• Codeine
Semi-synthetics
Modified Natural
• Heroin
• Vicodin
Synthetics
• Fentanyl
• Demerol
• Methadone
Heroin
•Heroin more potent -60-80% - <10% in ‘70’s
• Younger age group – 18-24 y.o. and younger
• Suburban/Rural
•Users start with snorting - IV within 12 months
•Withdrawal painful - not deadly
• Lots of Relapse
“Take the best orgasmyou’ve ever had…Multiply it by a thousand.And you’re still nowherenear it.
Heroin
Effects• Analgesia - change in pain
perception
• Euphoria - Intense
• Sedation - “on the nod”
• Respiratory Depression
• Cough Suppression
• Nausea/vomiting
• Constipation
Withdrawal• Pain
• Depression
• Alert
• Rapid Breathing
• Coughing
• Nausea/Vomiting
• Diarrhea
• 3-5 days
Addiction/Dependency
• Opioids trigger reward system – euphoria – leads to continued use –addiction
• Withdrawal symptoms are significant – regular use to avoid withdrawal - dependence
Addiction vs. Dependency
Addiction vs. Dependency
Addicted not Dependent Dependent not Addicted
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)
Prescription Opiates
•OxyContin
•Vicodin
•Hysingla ER
Overdose Reversal Kits
• Kits can save lives
• Over 90,000 trained in NY
• 2,900 known reversals
• Available Over the Counter at pharmacies
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
Then vs. Now
Marijuana
•Used since 2,700 BC
•More potent today (5-10X) than ‘70’s
•Kids starting younger
• Eliminates boredom, focus concentration, lowered anxiety, euphoric, increased appetite.
Butane Hash Oil• Newest trend – aka
“Dabs”
• THC extracted from MJ with butane
• 30-80% THC
• Dangerous
Spice/K2 and Synthetic Cannabinoids
Preparation of the “Incense”:
Botanicals are sprayed with liquid preparations of:
• HU-210
• HU-211
• CP 47,497
• JWH-018
• JWH-073
Origins of Synthetic Cannabinoids
• HU-210 & HU-211 - synthesized at Hebrew University, Israel in 1988. HU-210 is an anti-inflammatory; HU-211 as an anesthetic
• CP 47,497 - developed by Pfizer in 1980 as an analgesic
• JWH-018 & JWH-073 - synthesize by a researcher at Clemson (1995) for use in THC receptor research - John W. Huffman
• more than 100 different synthetic cannabinoids have been created
Similar to THC, but…
•Psychotic episodes
•Herbal incense blends are harsher to inhale
• Increased restlessness & aggressive behavior
•Doesn’t mix well with alcohol (hangovers)
Bath Salts:
• Ivory Wave
• Ivory Pure
• Ivory Coast
• Purple Wave
• Vanilla Sky
What’s in Bath Salts?:
• Methylenedioxypyrovalerone (MDPV) is a psychoactive drug with stimulant properties
• MDPV has four times the potency of Ritalin
• MDPV - no history of FDA approved medical use
Pharmacological Effects of “Bath Salts”:• increase heart rate & blood pressure
• pupil dilation
• hyperactivity, arousal & over stimulation
• increased energy & motivation
• euphoria - agitation
• dizziness
• nausea
• breathing difficulties
• diminished perception of the requirement for food and sleep
Molly/MDMA/Ecstasy
Whatismolly.com
MDMA/Molly/XTC
• Club drugs – produce feelings of belongingness, warmth and affection
• Intense euphoric high
• Provide energy for dancing – raves
• Less hallucinogenic
• Dangers – teeth grinding (pacifiers)
• Hyperthermia/dehydration
• Hyponatremia (low salt) water intoxication – can be lethal
Effects of MDMA on Brain Function
Addiction is like…
• The dog does not want to let go of the bone (addiction/ denial).
• It gets excited when it thinks its going to get its bone (craving)
• It always wants more bones (loss of control)
• Dogs live in the moment…no planning
A dog with a bone
What Boomer is Thinking
What can I getaway with?They won’t test me
for another week.
Try the second-hand smoke
excuse.We can talk our way out of this.
Treatment is like…
• You teach the dog’s owner to control the dog.
• You develop a variety of tools (relapse prevention) to help the dog be obedient.
• Some dogs are harder to train.
Obedience School for the Dog
Early Recovery Issues
• Loss of lifestyle
• Loss of Coping Strategy
•Withdrawal
•Cognitive deficits related to early abstinence
Cognitive Deficits
• Memory problems - short term loss
• Difficulty with abstractions
• Difficulty with impulse control
• Similar performance to those with brain damage -Improves.
The EndThanks
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