Opioid Crisis in America A Big Mistake an
Opioid Crisis in America: A Big Mistake, an Aggressive Industry, a Tricky Brain, and the 16 Milligrams that Will Bring Your Child Back to College Petros Levounis, MD, MA Professor and Chair Rutgers New Jersey Medical School Newark, New Jersey From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. San Antonio, Texas: August 21 to 23, 2017
Learning Objectives After attending this presentation, learners will be able to: �Describe the basic model of addiction. �List three safe and effective treatments for opioid use disorder. �Discuss mindfulness in the treatment of addiction. Slide 2 of XX MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. From P Levounis, Slide 2 of 38
Outline 1. 2. 3. 4. 5. Slide 3 of 38 The Basic Model The Neurobiology of Addiction Treatments New Directions Conclusions 3 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide of 38 1 The Basic Model From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
A Biopsychosocial Illness Slide 5 of 38 Biological Addiction Psychological Social Use Brain Switch Olsen and Levounis, Sober Siblings, 2008. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. 5
The Root Cause of the Disaster Porter and Jick, N Engl J Med, January 10, 1980. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. Slide of 38
Pharma Slide 7 of 38 7
Admissions: 1999 Slide 8 of 38 Primary non-heroin opioid admission rates (per 100, 000) 8 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Admissions: 2001 Slide 9 of 38 Primary non-heroin opioid admission rates (per 100, 000) 9 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Admissions: 2003 Slide 10 of 38 Primary non-heroin opioid admission rates (per 100, 000) 10 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Admissions: 2005 Slide 11 of 38 Primary non-heroin opioid admission rates (per 100, 000) 11 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Admissions: 2007 Slide 12 of 38 Primary non-heroin opioid admission rates (per 100, 000) 12 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Admissions: 2009 Slide 13 of 38 Primary non-heroin opioid admission rates (per 100, 000) 13 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide 14 of 38 Marked Geographic Variation in Mortality: Mortality Estimated Ageadjusted Death Rates for Drug Poisoning by County 1999 Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 14 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide 15 of 38 Marked Geographic Variation in Mortality: Mortality Estimated Ageadjusted Death Rates for Drug Poisoning by County 2002 Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 15 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide 16 of 38 Marked Geographic Variation in Mortality: Mortality Estimated Ageadjusted Death Rates for Drug Poisoning by County 2005 Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 16 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide 17 of 38 Marked Geographic Variation in Mortality: Mortality Estimated Ageadjusted Death Rates for Drug Poisoning by County 2008 Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 17 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide 18 of 38 Marked Geographic Variation in Mortality: Mortality Estimated Ageadjusted Death Rates for Drug Poisoning by County 2011 Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 18 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide 19 of 38 Marked Geographic Variation in Mortality: Mortality Estimated Ageadjusted Death Rates for Drug Poisoning by County 2014 Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 19 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
From Pills to Heroin Compton, New England Journal of Medicine, 2016. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. Slide 20 of 38 20
Slide of 38 2 The Neurobiology of Addiction From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide of 38 Natural Rewards DA Concentration (% Baseline) Food % of Basal DA Output 200 150 100 Empty 50 Box Feeding 0 0 60 120 180 Time (min) Sex 200 150 100 Sample 1 Number Female Present 2 3 4 5 6 7 8 Adapted from: Di Chiara et al, Neuroscience, 1999 Adapted from: Fiorino and Phillips, J Neuroscience, 1997 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Effects of Drugs on Dopamine Levels MORPHINE Dose mg/kg 0. 5 1. 0 2. 5 10 200 150 100 0 0 1 2 150 100 300 200 100 0 5 hr 1 2 3 4 5 hr ETHANOL Dose (g/kg ip) 200 0. 25 0. 5 1 2. 5 150 100 0 250 % of Basal Release 200 0 4 NICOTINE 250 % of Basal Release 3 COCAINE 400 % of Basal Release 250 Slide 23 of 38 0 1 2 3 4 hr Adapted from: Di Chiara and Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of From P Levounis, MD, Nora MA at. DSan Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. Volkow, MD 23
Pleasure-Reward Pathways National Institute on Drug Abuse, www. nida. nih. gov, 2000. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. Slide 24 of 38 24
Slide of 38 3 Addiction Treatments From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide 26 of 38 1 st Wave: Psychoanalysis Levounis, Journal of Medical Toxicology, 2016. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. 26 26
Slide 27 of 38 2 nd Wave: Boot Camps DISASTER 27 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. 27
3 rd Wave: The Current Approach Slide 28 of 38 1. Mutual Help Groups (12 -step) 2. Motivational Interviewing (and CBT) 3. Medications 4. Family Therapy 5. Primary Care Services 6. Mental Health Services 7. Aftercare Nunes, Selzer, Levounis, Davies, Substance Dependence and Co-Occurring Psychiatric Disorders, 2010. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. 28
Mutual Help MEDICAL STAFF PATIENTS 1. Housing 2. Gov’t Services 3. Medical Services 4. Outpatient Tx 5. Job 6. Community 7. Trusting People 8. Inner peace 9. God 10. Spirituality 11. AA 1. Inner peace 2. God 3. Medical Services 4. AA 5. Housing 6. Spirituality 7. Outpatient Tx 8. Community 9. Gov’t Services 10. Trusting People 11. Job Slide 29 of 38 What Med Staff Think Patients Think 1. Housing 2. Outpatient Tx 3. Medical Services 4. Job 5. Trusting People 6. AA 7. Inner Peace 8. Community 9. Gov’t Services 10. Spirituality 11. God Goldfarb, Am J Drug Alcohol Abuse, 1996. Levounis, Zerbo, and Aggarwal, Pocket Guide to Addiction Assessment and Treatment, 2017. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. 29
Motivational Interviewing Levounis, Arnaout, and Marienfeld, Motivational Interviewing for Clinical Practice, 2017. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. Slide 30 of 38 30
Slide 31 of 38 Medications 100 Full Agonist (Methadone) 90 80 70 % Efficacy 60 50 Partial Agonist (Buprenorphine) 40 30 20 10 Antagonist (Naltrexone) 0 -10 -9 -8 -7 -6 -5 -4 Log Dose of Opioid Renner and Levounis, Office-Based Buprenorphine Treatment of Opioid Dependence, APA Publishing, 2011. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. 31
Slide of 38 4 New Directions From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
4 th Wave: Mindfulness Slide 33 of 38 “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lie our growth and our freedom. ” Viktor E. Frankl V, Man’s Search for Meaning, 1959. Zerbo, Schlechter, Desai, and Levounis, Becoming Mindful, 2017. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. 33
% reporting any substance use disorders And Back to Psychodynamics… Slide 34 of 38 *** Ref * *** * Ref Women Men *p<0. 05, ***p<. 001 based on logistic regression analysis adjusted for race, age, educational level, personal income, employment status, relationship status, health insurance status, geographic location, MSA, age at alcohol onset, and family history of AOD problems. Reference group was “heterosexual” group. Mc. Cabe SE, Addiction, 2009; courtesy of Sean Mc. Cabe, Ph. D. Levounis, Drescher, and Barber, The LGBT Casebook, 2012. From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA. 34
Slide of 38 5 Conclusions From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide 36 of 38 1. Addiction hijacks the pleasure/reward pathways of the brain and weakens the frontal lobes. 2. Mutual help, motivational interviewing, and partial agonists are the foundations of addiction treatment in 2017. 36 From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
Slide of 38 Thank you From P Levounis, MD, MA at San Antonio, Texas, August 21 -23, 2017, Ryan White HIV/AIDS Program Clinical Conference, IAS USA.
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