Heroin : A Brain Disease

Heroin: A Brain Disease

Rick Ryan, MD, FACEPProfessor and Vice Chairman, Department of Emergency MedicineUniversity of Cincinnati

Objectives: HeroinTo understand common misconceptions about addiction

To comprehend the scale of local and national opiate useTo understand how we arrived at this epidemicTo understand cardinal features and contributing factors of addiction and how this effects the brain and other organsRecall the basic drugs used to “treat” heroin/opiate addictionState a few strategies on “what can be done”

Addiction

Addiction is a chronic, often relapsing brain disease that causes compulsive drug seeking and use, despite harmful consequences to the addicted individual and to those around him or her.Although the initial decision to take drugs is voluntary for most people, the brain changes that occur over time challenge an addicted person’s self-control and hamper his or her ability to resist intense impulses to take drugs.

Why Do Some People Become Addicted While Others Do Not?

No single factor can predict whether a person will become addicted to drugs. Risk for addiction is influenced by a combination of factors that include individual biology, social environment, and age or stage of development. The more risk factors an individual has, the greater the chance that taking drugs can lead to addiction.

Biology/GeneticsGenes

No single geneGenetics accounts for about half of ones addiction vulnerabilityTwin studyGender, ethnicity, and the presence of other mental disorders may influence risk for drug abuse and addiction.

Environment

Family and friends Socioeconomic status and quality of life in generalPeer pressure, physical and sexual abuse, stress, and quality of parenting can greatly influence the occurrence of drug abuse and the escalation to addiction in a person’s life.

DevelopmentThe

earlier that drug use begins, the more likely it will progress to more serious abuse, which poses a special challenge to adolescents. Because areas in their brains that govern decision making, judgment, and self-control are still developing, adolescents may be especially prone to risk-taking behaviors, including trying drugs of abuse.

Misconceptions

Misconceptions: Moral vs. DiseaseMoral

“Choice”“weak self-will”DiseaseActivated by a “choice”Cancers: smokeDiabetes: foodNobody chooses addiction

Misconceptions: Moral vs. DiseaseMoral model leads to the stigma associated with addiction, alcoholism

Afraid Influences care providers actions also“treat and street”empathy

Misconceptions Regarding Opioids and Addiction

Volkow

ND, McLellan AT. N

Engl

J Med 2016;374:1253-1263

Stats

Heroin StatsMore

people died from drug overdoses in 2014 than in any year on record6 of 10 from opioids2014: 2,000,000 Americans abused or dependent2002-2013: 18-25 yo highest increase in heroin useStudies suggest that regional variation in use of prescription opioids cannot be explained by the underlying health status of the population.

Cross-addiction

Why do we have a heroin problem?

A few reasons why the heroin problem exists:

Bad research: 1950 Boston University12,000 patients, 4 addictions“Addictions rare in patients treated with narcotics”NEJM 1980Medical Pharmaceutical MarketingDirect advertisings: medical mags“Drug Reps”CME: trips, dinnersEx) Valium

1st million/billion dollar drugJCAHO, VA

5th Vital Sign; 1998

A few reasons why the heroin problem exists:

“Undertreating pain”Chronic painPatient surveysIf no Rx=low score=no job and decreased reimbursementMedicare reimbursementBased on satisfaction surveysHMO’sIncreased pts/hr

Less time with patient (13 minutes)

A few reasons why the heroin problem exists:

“Pill Mills”Portsmouth, OHPrograms to reduce pill availabilityHeroin is “cheap”, available2008: 500 kg seized at border2013: 2196 kg seized at border

Features and Factors of Addiction

Cardinal Features of Addiction

Craving for the drugObsessive thinking about the drugErosion of inhibitory control over efforts to refrain from drug useCompulsive drug takingThese behavioral changes in turn are associated with structural and functional changes in the reward, inhibitory, and emotional circuits of the brainGenetics accounts for at least 40% of the risk associated with addiction

Contributing Factors Associated with ODType

DosePotency Duration of action

The Brain (and other organs)

What Happens to Your Brain When You Take Drugs?Drugs contain chemicals that tap into the brain’s communication system and disrupt the way nerve cells normally send, receive, and process information.

There are at least two ways that drugs cause this disruption: (1) by imitating the brain’s natural chemical messengers and (2) by overstimulating the “reward circuit” of the brain.

Drugs of abuse bind to the neural circuitry of REWARD

The Brain: Endorphins“endogenous morphine”

Opioid neuropeptidesReleased from pituitary glandExerciseEmotional stressPainSexFeelings of pleasure or euphoria

What Happens to Your Brain When You Take Drugs?As a person continues to abuse drugs, the brain adapts to the overwhelming surges in dopamine by producing less dopamine or by reducing the number of dopamine receptors in the reward circuit.

The result is a lessening of dopamine’s impact on the reward circuit, which reduces the abuser’s ability to enjoy not only the drugs but also other events in life that previously brought pleasure. This decrease compels the addicted person to keep abusing drugs in an attempt to bring the dopamine function back to normal, but now larger amounts of the drug are required to achieve the same dopamine high—an effect known as tolerance

What Happens to Your Brain When You Take Drugs?Long-term abuse causes changes in other brain chemical systems and circuits as well

.Brain imaging studies of drug-addicted individuals show changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control.These changes can drive an abuser to seek out and take drugs compulsively despite adverse, even devastating consequences—that is the nature of addiction.

Volkow

ND, McLellan AT. N

Engl

J Med 2016;374:1253-1263.

Location

of Mu-Opioid Receptors.

Opiate overview/examples

Opiate examples

Pharmaceuticals used to “treat” opiate addiction

Pharmaceuticals used for opiate addictionNaloxone (

Narcan)Naltrexone (Vivitrol)Buprenorphine with naloxone (Suboxone)Abuse potentialTreatment programMethadone

Abuse potentialTreatment program

Naloxone

NaltrexoneIndications

Treat alcohol dependencePrevent relapse to opioid dependence (after opioid detox)Must be used with alcohol or drug recovery programs

Buprenorphine and naloxone2013

2.4 million abused or dependent on opioidsTreat opioid dependencePart of a complete treatment planCounselingPsychosocial

What can be done?

Nothing until “The Bottom”Definition varies per individual

What may be your “bottom” may not be someone else'sResponse may be anger, confusion, “sense of failure”

What can be done?

Expand access to evidence-based substance abuse treatment, such as Medication-Assisted Treatment, for people already struggling with opioid addictionExpand access to treatment facilitiesExpand access and use of naloxonePromote the use of state prescription drug monitoring programs

Implement and strengthen state strategies that help prevent high-risk prescribing and prevent opioid overdose.Improve detection of the trends of illegal opioid use by working with state and local public health agencies, medical examiners and coroners, and law enforcement.

Volkow

ND, McLellan AT. N

Engl

J Med 2016;374:1253-1263

Access to CareDetox

InpatientAftercareIntensive outpatientPsychosocial12 step programs (AA, NA, CA)

Heroin Rehab

Heroin detox.Counseling – either individually or in a group or both.Behavioral therapy.Addiction education.Dual diagnosis treatment and care for any additional medical conditions you may have.Relapse prevention skill training.Support group participation.Aftercare

Questions?

Commonly Used Terms

Opioid use disorderA problematic pattern of opioid use that causes clinically significant impairment or distress. A diagnosis is based on specific criteria such as unsuccessful efforts to cut down or control use, as well as use resulting in social problems and a failure to fulfill obligations at work, school, or home. Opioid use disorder has also been referred to as “opioid abuse or dependence” or “opioid addiction.”Physical dependenceAdaptation to a drug that produces symptoms of withdrawal when the drug is stopped.

ToleranceReduced response to a drug with repeated use. 

Commonly Used TermsDrug misuse

The use of prescription drugs without a prescription, or in a manner other than as directed by the prescriber.OverdoseInjury to the body that happens when a drug is taken in excessive amounts. An overdose can be fatal or nonfatal.Medication-assisted treatment (MAT)Treatment for opioid use disorder combining the use of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies.