So my name is Dr. Yngvild Olsen and I am in addiction medicine physician specialist, here in Baltimore City. Today, we're going to be talking about opioid addiction and its treatment. So we're going to start with a case. This is a 38-year-old female who's been using heroin and cocaine intravenously for about 20 years, has never been in treatment, but had to prior arrests for possession, serving sentences for both. She has hepatitis C, depression, hypertension, and diabetes, but unfortunately no regular health care. She came to the emergency department for a headache, and had a very elevated blood pressure of 190 over 110, and a finger stick that was very high at 380. The emergency department physician, mentioned substance use disorder treatment, including a medication, perhaps methadone or buprenorphine. But she has a number of questions. Isn't being on one of those medications particularly methadone or buprenorphine, just substituting one addiction for another? How long would I need to take it? What will happen to me while I was taking either of those medicines? Will I go through withdrawal if I want to come off? What about that injectible medication I've heard so much about? So let's make sure that we're all on the same page as to what it is that we're talking about. So let's start with some basic definitions, particularly of addiction, because it is key to understand what this is. There are a number of different organizations including the American Society of Addiction Medicine, the National Institute on Drug Abuse, and most recently in the surgeon general's report, on alcohol drugs and health, that all have definitions of addiction, but that share different pieces of that definition. So for example ASAM, says that this is a primary chronic disease of brain reward, motivation, memory and other circuitry. NIDA calls addiction as a chronic relapsing disease, characterized by compulsive drug seeking. The Surgeon General, describes addiction as a chronic brain disease that has the potential for recurrence and recovery. The keywords here are that it is a chronic, relapsing disease of the brain, but that has chance for recovery. Another way to think about this, is as substance use disorders. This is defined in the Diagnostic and Statistical Manual for the American Psychiatric Association. That manual describes a group of diagnosis, that all have common predisposing factors, brain dysfunction and diagnostic features. But they are separated by the specific substance involved, and they are also then characterized as mild, moderate or severe, based on how many of those diagnostic features are present. When we say addiction is a chronic disease, what does that really mean? Well, for one it means that there is no cure. However, as recovery, the goal is lifelong management of the disease. The disease severity may change over time, but the risk of symptom recurrence is always present. As with many other chronic diseases like diabetes or high blood pressure, effective treatments often combine medications and behavioral interventions. Behavior change is a key part of management but it occurs in stages. This is one model of how we can think about behavior change. Based on the work from Prochaska and DiClemente, and it takes people through different stages. From what's called pre-contemplation, when really people don't think that they have a problem at all, to contemplation, preparation and action, when people really start changing their behavior, and the maintenance, which is really the recovery stage, and people then are sustaining and strengthening the changes they have made. We'll get back to this later. So the question I often get asked is, why do some people develop an addiction and others don't? The answer lies in the complex interactions of multiple factors, including having to do with biology and genes, the environment and some mechanisms related to the drug themselves. Really creating a perfect storm in any one individual. So in terms of the genetic contribution, we know that about 40 to 60 percent of the risk of developing a substance use disorder is genetically based. Although we have research showing us some of what those genetic variants may be, there's probably not just one that is involved. To date, up to a 100 genetic variants, have been identified. The genetic risks related to those, is probably not specific to one type of substance use disorder. In addition, research is ongoing to clarify the exact functional significance of these different genetic variants or so-called physio genetics. Interestingly, some of those genetic variants may really be more implicated in responses to different medications, an area that's called now pharmacogenetics. A lot of research is ongoing, to try and further elucidate both the physiogenetics, as well as the pharmacogenetics. The other major risk factor for people with substance use disorders, is the presence of other mental illnesses. We know that about 35 percent of people who have an alcohol use disorder, and over 50 percent of those with a drug use disorder, have some other type of mental illness. There's some data to suggest that children with ADHD, particularly when untreated, are at higher risk for cocaine use disorder later in life. This shows you some of the odds ratios for both alcohol and drug use disorder, and their relations to any other lifetime mental illness. This is old data but as you can see, the people with alcohol or drug use disorders have much higher odds of schizophrenia, affective, or mood disorders such as depression or anxiety. A third major risk factor that we are now beginning to understand much better, is the impact of trauma. This is data from the adverse childhood experiences study, that interviewed over 8,000 adult men and women in the general population across the US, and asked about history of abuse, neglect and other types of traumatic experiences, prior to the age of 18. They assigned each participant what's called an ACE score or an adverse childhood experience score, based on the number of those experiences, anywhere between zero and five or more. In this general population, 67 percent had at least one adverse childhood experience. Forty two percent had two or more. Remember this is among the general public. So trauma is really common. Here, this slide shows you some of the relationship of these ACE scores to ever having had a drug problem, ever being addicted to drugs or injecting illicit drugs. As you can see, as the ACE score increases, the odds of these outcomes related to drug use, go up significantly. So trauma is certainly something we need to really be on the lookout for. The age of first use is also important. Because multiple studies demonstrate that there is a higher risk of adult onset substance use disorders, with early onset of use before the age of 14. As the ACE study showed us, that in kids who have experienced childhood trauma, they are much more likely to use substances particularly early on. The impact of early onset of substance use and its association with substance use disorders in adulthood, is probably related to the higher vulnerability of the adolescent brain, as it goes through significant developmental changes up until about age 25. We also think that there may be some differential gene expression during adolescents compared to adulthood. So those genetic predispositions, really may play a big part of why adolescents are particularly vulnerable to the consequences of substance use. The other significant area that we need to think about in terms of risk factors, has to do with the addictive potential of different substances. So for example, the faster a drug gets to the brain, the higher the addictive potential. So snorting, smoking, injecting, gets substances to the brain really fast, much more so than taking a medication or substance orally, or putting it on the skin and having it absorbed through that way. The shorter acting a drug is, the higher the addictive the potential. So things like heroin, cocaine, Xanax which is a very short acting benzodiazepine, have a much higher addictive potential compared to things like methadone or buprenorphine, that are taken orally and act much more slowly and much longer. The more potent that drugs are, the higher the addictive potential because it takes less of the drug to achieve an effect. So things like heroin, cocaine, now fentanyl, and all the illicit fentanyl analogs that are driving the opioid epidemic and fatal overdoses, they're extremely potent. Especially when compared to things like methadone or buprenorphine or even oxycontin taken orally and as prescribed.
