John C Tanner DO DipABAM FASAM CCFC MRO Thurs April 30 2015 530 to 550 PM PRN Disclosure of Relevant Financial Relationships Name Commercial Interests Relevant Financial Relationships What Was Received ID: 798209
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Slide1
Help for Impaired Professionals - Part I
John C. Tanner, D.O., Dip.ABAM, FASAM, CCFC, MRO Thurs. April 30, 2015 5:30 to 5:50 PM
PRN
Slide2Disclosure of Relevant
Financial
Relationships
Name
Commercial Interests
Relevant Financial Relationships: What Was Received
Relevant Financial Relationships: For What Role
No Relevant Financial Relationships with Any Commercial Interests
John C Tanner, DO, DipABAB, FASAM, CCFC, MRO
Reckitt Benckiser
Honorarium
Consultant & Speaker
BDSI
Honorarium
Consultant &
Speaker
Orexo
Honorarium
Consultant & Speaker
Slide3John C. Tanner,
DO, DipABAM, FASAM, CCFC, MRO
Medical Director for Intervention Project for Nurses – Florida (IPN).Former Assistant Medical Director for Professionals Resource Network (PRN).
Medical Director for West Virginia Restore.One of 6 Directors-at-Large for the American Society of Addiction Medicine’s Board of Directors - elected for 2 consecutive terms through 2019.
Fellow of the American Society of Addiction Medicine.Serving on the Board of Directors for the Florida Society of Addiction Medicine.Inaugural Diplomate of the American Board of Addiction Medicine.
Assistant Professor - Department of Psychiatry – University of Florida School of Medicine.Private Addiction and Behavioral Medicine practice since 1984.One of 3 Principle Investigators for the FDA Phase 2 and 3 Clinical Trials for approval of Suboxone® Film.
Medical Review Officer – MROCC Certified.Clinically Certified Forensic Counselor.
Slide4Are you or a health professional you know not firing on all eight?
Is it impairing functioning or judgment?
Might it be related to a psychoactive substance or mental health issue?
Slide5Hipp
Amyg
Memory &
learning (7 & 8)
OFC
SCC
Motivation &
drive (3 & 4)
NAc
VP
Reward & Salience
(5 & 6)
Eight areas involved with
survival
and addiction
PFC
ACG
Executive function & inhibitory control
(1 & 2)
1) PFC
= prefrontal cortex
2) ACG
= anterior cingulate gyrus
3) OFC
= orbitofrontal cortex
4) SCC
= subcallosal cortex
5) NAc
= nucleus accumbens
6) VP
= ventral pallidum
7) Hipp
= hippocampus
8) Amyg
= amygdala
Slide6This is a story that can have
a bad outcome
or a good outcome
depending on how you handle it.
Slide7The consequences
of addiction:
Prison
Accidental death Suicide
Other bad outcomes
Slide8The consequences of
addiction: prison
Slide9A consequence of addiction
: Accidental death
Slide10The consequences
of addiction: accidental overdose
Slide11A consequence
of addiction:
Suicide
Slide12The consequences
of addiction: errors in judgment
Slide13The consequences
of addiction: harm to patient
Slide14The consequences of addiction: medical malpractice suits
Slide15The consequences - marital
and family dysfunction
Slide16Mental
health problems such as
Bipolar Affective Disorder, Eating Disorders and
others that can result in impairment need to be monitored
---
Slide17Offending sexual boundaries
Slide18Impaired practitioner legislation provides:
Recognition that illness and recovery can be
mitigating factors in Licensing Board action.
An opportunity for a licensee to reenter practice
after satisfactorily completing appropriate treatment and demonstrating progress with
recovery.
Slide19Impaired practitioner legislation provides:
Increased incentive for self reporting.
Early intervention.
Increased incentive for entry into treatment.
Slide20Reporting to:
impaired practitioner program
vs. Licensing Board
Professionals Resource Network and Intervention Project for
Nurses: Are confidential and provide for treatment along with
advocacy.
Licensing Boards: Information becomes public and action is
more likely disciplinary.
Slide21Thank you for
listening (Part II is tomorrow)
John C. Tanner, DO, DipABAM, FASAM,CCFC, MRO
IPN# 800-840-2720 My Ext 146
PRN# 800-888-8776
Questions
Slide22Help for Impaired Professionals - Part II
John C. Tanner, D.O., Dip.ABAM, FASAM, CCFC, MRO Friday May 1, 2015 4:55 to 5:15 PM
PRN
Slide23Disclosure of Relevant
Financial
Relationships
Name
Commercial Interests
Relevant Financial Relationships: What Was Received
Relevant Financial Relationships: For What Role
No Relevant Financial Relationships with Any Commercial Interests
John C Tanner, DO, DipABAB, FASAM, CCFC, MRO
Reckitt Benckiser
Honorarium
Consultant & Speaker
BDSI
Honorarium
Consultant &
Speaker
Orexo
Honorarium
Consultant & Speaker
Slide24John C. Tanner,
DO, DipABAM, FASAM, CCFC, MRO
Medical Director for Intervention Project for Nurses – Florida (IPN).Former Assistant Medical Director for Professionals Resource Network (PRN).
Medical Director for West Virginia Restore.One of 6 Directors-at-Large for the American Society of Addiction Medicine’s Board of Directors - elected for 2 consecutive terms through 2019.Fellow of the American Society of Addiction Medicine.
Serving on the Board of Directors for the Florida Society of Addiction Medicine.Inaugural Diplomate of the American Board of Addiction Medicine.
Adjunct Assistant Professor - Department of Psychiatry – University of Florida School of Medicine.Private Addiction and Behavioral Medicine practice since 1984.One of 3 Principle Investigators for the FDA Phase 2 and 3 Clinical Trials for approval of Suboxone® Film.
Medical Review Officer – MROCC Certified.Clinically Certified Forensic Counselor.
Slide25Are you or a health professional you know not firing on all eight?
Is it impairing functioning or judgment?
Might it be related to a psychoactive substance or mental health issue?
Slide26The 8 that are not firing
are not here
Slide27The 8 gray-matter areas that are not firing
are here
Slide28The 8 nuclei are divided in these regions
Pre Frontal Cortex
Limbic Region
Slide29Treatment: the target areas
Pre Frontal Cortex
Role:
Decision Making, Impulse
Control, Judgment
Intervention:
Counseling, Mutual Support
Limbic Region
Role:
Reward, Emotions,
Drive Generation
Intervention
: Pharmacotherapy
So what does this have to do with safety?
Slide30Hipp
Amyg
Memory &
learning (7 & 8)
OFC
SCC
Motivation &
drive (3 & 4)
NAc
VP
Reward & Salience
(5 & 6)
Eight areas involved with survival and addiction
PFC
ACG
Executive function & inhibitory control
(1 & 2)
1) PFC
= prefrontal cortex
2) ACG
= anterior cingulate gyrus
3) OFC
= orbitofrontal cortex
4) SCC
= subcallosal cortex
5) NAc
= nucleus accumbens
6) VP
= ventral pallidum
7) Hipp
= hippocampus
8) Amyg
= amygdala
Slide31Brain centers involved in survival and addiction
A more precise
anatomic
location of
the 8 areas
1
2
3
4
5
6
7
8
Slide32What is it that makes us survive and thrive as people?
Does it a have a powerful influence on our behavior?
How does it work to make us behave to survive or thrive?Can it be influenced by anything?If influenced, by what?
Slide33Social needs: Does this relate to survival?
Slide34Food & fluids
: Is this really about survival?
Slide35Sexual drive:
Is this really about making babies???
Slide36Gender differences in cerebral
activation when viewing erotic stimuli in fMRI
Reference: University Clinic Essen 03/01/2006; Elke
Gizewski, MD, Elke Gizewski
For analysis of specific activation, the contrast images of all groups were entered into a two-sample t-test. Interaction-related increase in MR signal is superimposed on three orthogonal sections of 3-D T1 weighted standard brain.
When viewing erotic film excerpts, statistical parametric maps of areas activated more prominently in men compared with women. Results show activation of left thalamus, left amygdala, anterior cingulate, bilateral orbitofrontal, and insular cortex
Slide37fMRI images of a woman's brain throughout an orgasm
References:
Rutgers University and the University of Groningen in the Netherlands
More than 30 areas of the brain are active during the event, including those involved in touch, memory, reward and even pain
PFC becomes more active during orgasm, whether it’s achieved through physical touch or thought alone
PFC evidently “shuts off” during orgasm – especially a region of the orbitofrontal cortex (OFC), which is involved in the process of self-control
Slide38Executive function/inhibitory circuits - Interventions: psychotherapy and mutual community supports
PFC
ACG
Executive
function &
inhibitory
control
PFC
= prefrontal cortex
ACG
= anterior cingulate gyrus
Slide39Executive function/inhibitory circuits – Intervention:
Facilitated support groups
PFC
= prefrontal cortex
ACG
= anterior cingulate gyrus
FSG
Where peermentoring andhealing occurs
Slide40Executive
function/inhibitory circuits – Intervention:mutual support groups
Alcoholics Anonymous (aa.org), Narcotics Anonymous, Women for Sobriety (womenforsobriety.org), Abstinence based SMART Recovery(smartrecovery.org), Secular Organizations for Sobriety (secularsobriety.org), faith based support group like Celebrate Recovery
PFC
= prefrontal cortex
ACG
= anterior cingulate gyrus
Slide41IPN/PRN
– Toxicology TestingA critical aspect of
monitoring
Or, as the nurses say “I
pee’n
for IPN”
Executive function/inhibitory circuits – Intervention:
Reinforcement of inhibitory supports with toxicology testing
PFC
= prefrontal cortex
ACG
= anterior cingulate gyrus
Slide42Executive function/inhibitory circuits Intervention:
Psychotherapy
is some times required
PFC
= prefrontal cortex
ACG
= anterior cingulate gyrus
Slide43Motivation & drive circuits - Intervention: medications Timelines for
FDA-Approved Pharmacotherapies
1951
1994
2004
2006
Antabuse
®
(disulfiram)
Actually works in inhibitory
control area (PFC & ASG)
ReVia
®
/Depade
®
(naltrexone)
Campral
®
(Acamprosate)
Vivitrol 380 mg
®
(naltrexone for extended-release injectable suspension)
1964
1984
1993
2002
Methadose
®
/Dolophine
®
(methadone)
LAAM
Subutex
®
/Suboxone
®
(buprenorphine/naloxone)
ReVia
®
/Depade
®
(naltrexone)
2010
Vivitrol 380 mg
®
(naltrexone for extended-release injectable suspension
)
Alcohol Dependence
Opioid Dependence
Suboxone Film
®
(buprenorphine/naloxone)
2013
2014
Bunavail
®
(
buprenorphine/naloxone
)
Zubsolv
®
(buprenorphine/
naloxone)
OFC
= orbitofrontal cortex
SCC
= subcallosal cortex
Slide44Motivation & drive circuits - Interventions: Appropriate use of the brain’s natural rewards
Enhance the healthy:
Social activitiesFood & Water
Sex (When appropriate)
Etc. (i.e. music hobbies)
OFC
= orbitofrontal cortex
SCC
= subcallosal cortex
Slide45NAc
VP
Reward region
Reward circuits:
Interventions: medications and avoidance of psychoactive substances
NAc
= nucleus accumbens
VP
= ventral pallidum
VP receives dopaminergic inputs from the ventral tegmental area, and GABAergic inputs from the nucleus accumbens. It is the relay
nucleus from the nucleus accumbens to the medial dorsal nucleus. The nucleus accumbens projects to the medial dorsal nucleus via
GABAergic medium spiny neurons. It is thus a component of the mesolimbic dopamine system, a pathway thought to be the major
neural correlate of addiction. Addictive drugs facilitate dopamine release in this system. The VP is thought to be the primary craving area
.
Slide46Reward
circuits:
Interventions: medications and avoidance of psychoactive substances
Using a physician who is knowledgeable about prescribing for people with addiction
Avoiding medications that increase dopamine release or block dopamine reuptake (i.e. opiates, stimulants, sedative/hypnotics etc.)Appropriate use of antagonist or partial agonist medications
NAc
= nucleus accumbens
VP
= ventral pallidum
Slide47What are the known underlying mechanisms of relapse?
1
Drugs that reward
*
Reference:
1. Shaham
et al., 2003
* NAc
= nucleus accumbens
VP
= ventral pallidum
*
Slide48Hipp
Amyg
Memory &
learning
Memory storage & circuits: Interventions: expanding memory i.e. “next bottom”, recalling consequences and relearning new behaviors.
Hipp
= hippocampus
Amyg
= amygdala
Slide49Memory storage & circuits: Interventions: expanding memory and new learning
Next bottom (working with therapist).
Learning recovery tools/12-steps. Recalling negative consequences of addiction behaviors. Relearning new behaviors that do not involve psychoactive substances (i.e. hobbies, new sober social connections, developing spirituality, exercise, healthy diet habits etc.)
Hipp
= hippocampus
Amyg
= amygdala
Slide50Slide51Chemical – MR Spectroscopy (MRS)
Safe (No X-Rays)
Noninvasive
Provides a snapshot of the neurochemistry within a defined volume of interest
Significantly increases the accuracy and specificity of
conventional MR imaging in differentiating
between disease states
Hunters Angle
Slide52Some of the metabolites seen on MRS
ppmMetabolite
Properties0.9-1.4
LipidsProducts of brain cell destruction
1.3 Lactate
Product of anaerobic glycolysis2.0N-acetylaspartate (NAA)
Neuron cell marker2.2-2.4
Glutamine (
Gtx)/GABANeurotransmitters
3.0Creatine (Cr)Energy metabolism3.2Choline (Cho)Cell membrane marker3.5myo-inositol (mI)
Glial cell marker, osmolyte,
hormone receptor mechanisms
1.48
Alanine
Present in meningiomas
Slide53Magnetic Resonance Spectroscopic Imaging and Relevance to Addiction
Ref: Ann N Y Acad Sci. 2010 February; 1187: 148–171.
doi: 10.1111/j.1749-6632.2009.05143.x
Summary of anatomically related metabolite changes with drugs of abuse
N-acetylaspartate
Choline
Creatine
myo-inositol
Amphetamine
___
___
___
Increase (TL)
None (PFC)
Methamphetamine
Decrease
(BG, FGM)
Increase
(FGM)
Decrease
(BG)
Increase
(FGM, FWM)
MDMA
Decrease
(FGM, HP)
None
(FGM, PWM, NC, HP, OCC)
___
___
Increase (PWM)
None (FMG, PWM, OCC)Cocaine
Decrease(FMG, TAH)
Increase (BG)
Increase (PWM)Increase
(FGM)
Slide54Magnetic Resonance Spectroscopic Imaging and Relevance to Addiction
Ref: Ann N Y Acad Sci. 2010 February; 1187: 148–171.
doi: 10.1111/j.1749-6632.2009.05143.x
Glutamate
GABA
Methamphetamine
Decrease in frontal gray matter
(Ernst & Chang, 2008)
_________
Cocaine
__________Decrease in prefrontal cortex(Ke et. al., 2004)Decrease in OCC(Hetherington et al., 2000)OpiatesDecrease in ACC (
Yucel
et al, 2007)
_________
Cannabis
Decrease in basal ganglia
(Chang et al., 2006)
_________
Alcohol
Increase in ACC
(Lee et al, 2007)
Decrease in BG
(
Miese
et al., 2006)
Decrease in OCC
(Behar et al., 1999)
Nicotine
No change in
HP (Galliant et al., 2008)Decrease in OCC(Epperson et al., 2005)
Summary of reported neurotransmitter changes with drugs of abuse
Slide55Magnetic Resonance Spectroscopic Imaging and Relevance to Addiction
Ref: Ann N Y Acad Sci. 2010 February; 1187: 148–171.
doi: 10.1111/j.1749-6632.2009.05143.x
Metabolite
Decrease
Increase
N-acetylaspartate (NAA)
Methamphetamine,
MDMA, Cocaine, Opiates, Cannabis, Alcohol, Nicotine, Toluene
Cocaine (acute administration)
Choline (Cho)Cannabis, AlcoholMethamphetamine, Cocaine, AlcoholCreatine (Cr)MethamphetamineCocaine, Cannabis, AlcoholMyo-Inositol (mI)
_____
Amphetamine, Methamphetamine, MDMA,
Cocaine, Alcohol, Toluene
Glutamate (Glx)
Methamphetamine,
Opiates, Cannabis
Alcohol
GABA
Cocaine, Alcohol, Nicotine
____
Simplified summary of overlapping metabolite findings across drug classes
Slide56Summary of MRS Drugs of Abuse Findings
Reductions in NAA and elevations in mI were observed almost universally indicating that drugs of abuse in general have a profound impact on neuronal health, energy metabolism and inflammatory processes.
The next most common metabolite changes involved alterations in Cho and Cr, suggesting that methamphetamine, cocaine, cannabis, and alcohol negatively influence cell membrane turnover as well as energy maintenance.
Methamphetamine, opiates, cannabis, and alcohol were found to alter Glx to some extent, while GABA was reduced by cocaine, alcohol and nicotine, together suggesting that drugs of abuse adversely impact neurotransmission.
Slide57Summary
There is appropriate help for professionals with impairing disordersResearch shows good outcomes for professionals monitored in programs like PRN and IPN
Your Florida professional license requires you to report medical professionals with impairment either to their licensing board or to PRN or IPN (in the case of nursing professions)
Slide58Thank you for
listening
John C. Tanner, DO, DipABAM, FASAM,CCFC, MRO
IPN# 800-840-2720 My Ext 146
PRN# 800-888-8776
Questions