Lecture 5 and 6 Flashcards
1
Q
True or False: US leads the world in prescription
A
TRUE.
2
Q
What was the important parts of the opioid epidemic(s)?
A
- In 2011, 219 million prescriptions were dispensed
- This suggests that almost every adult in the US would have enough pills to treat themselves for one month
- 2017 declared a national PH emergency
- 2.1 million people in the US were dx with OUD
- 6 fold increase in OD deaths since 1999
3
Q
How many symptoms do you need to be diagnosed with OUD?
A
2 of the following within one year in:
- Loss of Control
- Risky Use
- Social/Vocational Problem
- Pharmacological/Physical Symptoms (Exhibits withdrawal - not considered to be met for individuals taking opioids solely under appropriate medical supervision)
Mild: 2-3
Moderate: 4-5
Severe: 6+
4
Q
Why are they so addictive?
Endogenous opioid system
A
We had endogenous opioids, small painkilling peptides our bodies naturally produce:
- Endorphins
- Enkephalins
- Dynorphins
These bind and activate opioid receptors - widely distributed in the brain, spinal cord (also in the gastrointestinal system and other areas of the body)
5
Q
What are the opioid analgesic and reward effects?
A
- Opioids bind to receptors that are in high concentration in VTA and project to the NAc
- Stops GABA signaling from regulation dopamine release, resulting in a surge of dopamine
-Also throughout the pain network - responsible for processing pain- Bind to these receptors, preventing signaling
- Feedback from the PFC to the VTA helps someone overcome drives to engage in behaviors that may be unsafe of unwise, but we know this feedback loop is compromised in individuals who become addicted to drugs
6
Q
What is addiction the result of?
A
Addiction is a result of opioids binding to receptors in Ventral tegmental area (VTA) and dopamine is released into the nucleus accumbens
7
Q
What is nucleus accumbens?
A
Receives signals in real time from all over our bodies. Examples:
- Hormonal balance
- Body temperature
- Caloric balance
- Hydration
Ensures survival
Addiction is when these systems are overwritten or hijacked by a drug
8
Q
What is acute withdrawal syndrome?
A
- Gastrointestinal distress.
- Thermoregulation disturbances
- Insomnia
-Joint and muscle pain/cramps - Dysphoria
- Restlessness
- Anxiety
Between 1-5 days - many factors
9
Q
What are the neuroadaptations and functional changes?
A
Dopamine neurotransmitter receives signals through endogenous opioids and translate it into a memory and motivation signal (Pain or pleasure)
Low dopamine receptor availability shown in PET and compromised frontal cortical activity
- Lower brain activity in addicted individuals
10
Q
What is post-acute withdrawal syndrome (PAWS)
A
Symptoms can vary:
- Mood disturbances (anxiety and depression)
- Sleep problem
- Fatigue
11
Q
What is the Clinical Opiate Withdrawal Scale (COWS)?
A
- 11-item scale designed to be administered by a clinician
- Used in both inpatient and outpatient settings
- Rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time
- Score can help determine the stage or severity of opiate withdrawal and level of physical dependence on opiods
- This will inform use of suboxone
12
Q
What is the treatment for heroin?
A
Individuals are still addicted which includes being dependent
Next steps:
- For some, methadone or buprenorphine treatment is a better method for maintaining abstinence from heroin
- Most effective when used in conjunction with cognitive behavioral therapty, vocational or employmen t counseling, and support groups
13
Q
What is harm reduction?
A
“A focus on reducing the negative consequences of substance use for individuals, communities and societies… rather than focusing on decreasing or eliminating substance use.”
14
Q
What are examples of harm reduction?
A
- Needle distribution/recovery programs that distribute sterile needles
- MAT’s (Medication-assisted treatment) - substitution therapies that substitute illegal heroin, with legal, non-injection methadone or other prescribed opioids
- Naloxone programs that provide training to use an antidote to opioids to reserve an overdose thereby preventing brain injury, due to depressed breathing, and death
- Supervised consumption facilities that help prevent overdose deaths and other harms by providing a safer, supervised environment for people using substances
15
Q
What are Medication-Assisted Treatments for OUD? A type of harm reduction
A
- The use of FDA- approved medications, in combination with counseling and behavioral therapies, in the treatment of substance use disorders
- Only about 20 percent of Americans who have an opioid use disorders are being treated with buprenorphine, naltrexone, or methadone - this shows the extent of the barriers to treatment
- Medication-assitsed treatment (MAT) research suggests they are effective in treating OUDs.
16
Q
What are the 3 medications to treat opioid dependence?
A
Agonists (replacement/substitution) - binds to the receptor and produces biological response
Partial agonists - bind to receptors but elicit partial functional response, regardless of amount of drug administered
Antagonist (blockade) - binds to receptors but produce no functional response, while also preventing an agonist from binding at that receptor site
17
Q
What is methadone?
A
Synthetic full agonist - binds to Mu Opioid receptors (turns on the receptors)
- 1970s - for heroin addiction. less addictive
- Long acting (24-36 hours). Replacement medications to manage opiate addiction. (Heroin needed every hour or so)
- Keeps cravings and withdrawal under control
- IV use will cross blood brain barrier quickly and will produce euphoria
- Liquid form is given at the clinic to avoid the sale of pills, which can be crushed and abused
18
Q
What are the issues of methadone?
A
- Getting the correct dose takes some time in the beginning
- Must go somewhere every morning to get the medication - very inconvenient (liquid handcuffs)
- Most were blue-collar workers that must be at work in the morning
- You can overdose because it’s a full agonist
- Can produce euphoria at high dose
- Mixed with Benzo causes high similar to heroin
- Cardiac disturbances. Tachycardia can cause heart attack
- Takes a long time to dose down and stop
- Private clinics keep patients there for financial gain
- Withdrawal is difficult
19
Q
What are the benefits of methadone?
A
Large national and international data sets show:
- Decreases crime
- Decreases relapse
- Increases functioning
- Increases treatment retention/therapy/groups
- Maintaining a job
-Decreases HIV and help in community
20
Q
What is suboxone as Synthetic Partial Agonist (Buprenorphine) Agonist + Antagonist (Naloxone)?
A
- 1960s (good data from 1990s - present)
- Delivers very diminished opioid doses to the patient who is addicted to a stronger opioid
- Partly turns on the receptor (Mu opioid)
- Reduces/eliminates cravings
- Does not create euphoria (typically)
- Long acting 24 hours - good for maintenance
21
Q
What is suboxone as a partial agonist (buprenorphine) + antagonist (naloxone)?
A
- Don’t have to go to a clinic every morning (no liquid handcuffs)
- Doses remains the same
- Easier to titrate dose compared to methadone
- Very difficult to overdose (ceiling effect)
22
Q
What is naltrexone?
A
Antagonist
- Used of AUD and OUD
- Blocks the euphoric and sedative effects of opioids and alcohol
- If a person relapses and uses the problem drug, naltrexone prevents the feeling of getting high
- No abuse potential
- Patients on naltrexone may have reduced tolerance to opioids and may be unaware of their potential sensitivity to the same, or lower, doses of opioids that they used to take
- If stopped and patient uses again, they are at risk for an overdose
23
Q
What is vivitrol?
A
Naltrexone for extended-release injectable suspension
24
Q
What is medically assisted treatment (MAT) of opioid addiction is associated with?
A
- Decrease in the number of overdoses from heroin abuse
- Increases retention of patients in treatment
- Decreases drug use, infectious disease transmission
- Decreases in criminal activity
25
Why can you resist medically-assisted treatment (MAT)?
Lack of understanding: Belief that MAT involves "substituting one drug for another" is something that exists in communities against MAT's including the CJS
- Concepts of addiction don't fit the MAT framework
Diverting the Medication/abuse - Programs and facilities can implement procedures, to ensure medications are provided in a way that reduces risk for this
Cost - The medication, training staff, store, certifications, etc, cost money
26
Why did legislation eliminate the X-Waiver
- Required for a DEA (Drug Enforcement Administration) registration for a practitioner registrant to prescribe buprenorphine (e.g. Suboxone) for the treatment of opioid use disorder
- Increases access to Medically-Assisted Treatment (MAT)
- Prescribers must go through an 8 hours training on the treatment and management of patients with OUD
- The training requirements went into effect on June 21, 2023
27
How are medically assisted treatments (MATs) in the criminal justice settings
- Approximately 15% of state prison inmates 20% of inmates report regularly using opiates
- Approximately 35% of inmates report suffering from serious withdrawal symptoms
- Prisoners and jail inmates released to the community are between 10 and 40 times more likely to die of an opiod overdose than the general population, within the first few weeks after reentering society
- A leading cause of death among formerly incarcerated individuals is a drug overdose
- There is a strong correlational evidence indicates that providing methadone or buprenorphine both during custody and after release to the community is associated with substantially lower rates of opiate overdose and mortality
28
What is the incarcerated individuals and Medically-Assisted Treatment (MAT)
Despite substantial evidence supporting MAT for the treatment of OUDs, few jails or prisons offer this treatment
Current policies do not support MAT in all criminal justices settings
- Some jails and prisons have policies that prohibit the use of controlled substances (including the medications used in MAT)
- Detoxification and MATs are a condition of probation, yet many have difficulty obtaining them
29
What are the supervised injection/consumption sites?
- 2021 NYX became the first to establish 2 supervised injection sites in the US
- Cities in other countries had for year: Vancouver, Mexicali and Barcelona
- The Vancouver site is often referenced as a model - with about 1,700 individuals using it each month, the center is credited with reducing overdose deaths in its neighborhood and city
- Switzerland was the first country to open a super injection site in 1986
- Exist in Canada and Europe (about 100)
- In Switzerland, France and other European countries, reports suggest they decrease rates of infectious disease, overdose and even consumption... and they supply the heroin.
30
What are the supervised injection sites supplies?
- Syringes
- Sterile cookers
- Tourniquets
- Facilities that offer these provisions do not supply or inject clients with IV drugs
- Pipes for crack use
31
What are the secure environments for the supervised injection sites?
- Free from criminal prosecution
- Open booths keep clients in view of clinicians
- Legally sanctioned facilities are exempt from prosecution for having illicit drugs on the premises
32
What are the support for the supervised injection sites?
- Staff are equipped with crash kits to respond immediately to an overdose
- Detox management for people who request it
- Counselors and coordinators to bridge a gap to services
33
What is the Switzerland Heroin-Assisted Treatment Program?
1994 - Swiss legalized prescription heroin to combat fatal overdoses and HIV infection rates
- Heroin Assisted Treatment patients must have at least two years of opioid dependence before starting treatment
- Failed two other addiction treatments
- 18 years old
- Controversial - cause more deaths and addiction
- Data suggests it was helpful
- Decline in new users
- 64% reduction in overdose deaths
- 84% reduction in HIV
- Related crime decreased
- Now Heroine Assisted Treatment programs exist in Denmark, Germany, Luxembourg, the Netherlands, the United Kingdom and Canada
34
What is Neonatal Abstinence Syndrome?
- Passive exposure of the newborn occurs when a mother uses a neuroactive drug during her pregnancy
- When the infant is deprived of these substances through the birthing process, a withdrawal syndrome may develop
- Opiates/opioids are the drug most associated with NAS. (Including Mats)
- Other drugs can cause withdrawal as well
- And some illicit drugs cause toxicity, but not withdrawal
- 45-95% of exposed babies will develop NAS
35
What did the early data of NAS say?
2010-2017: mothers with opioide-related diagnoses documented at delivery increased by 131%
- Babies born with NAS increased by 82% nationally over the same period
- Increases were seen for nearly all states and demographic groups
36
What is the more recent US data about NAS?
2020 date from Healthcare Cost and Utilization Project (HCUP):
- Approximately 6 newborns were diagnosed with neonatal abstinence syndrome (NAS) for every 1,000 newborn hospital stays
- This is equal to one baby diagnosed with NAS every 24 minutes/ 59 daily
37
Has Neonatal Abstinence Syndrome (NAS)/ Neonatal Opioid Withdrawal Syndrome (NOWS) and maternal opioid use disorder been increasing and decreasing in hospital births?
It has been increasing
38
What is the economic impact of NAS?
Cost: Hospital stay for newborn with NAS approximately $7,800 in 2020
Without: $1,100
The average stay: NAS -> 9 days
Compared to 2 days for other newborns
39
Has the rate of NAS per 1000 Births US
The rate of NAS steadily increased until 2017 and has been decreasing until 2021
40
What are the risk of Opioid Use During Pregnancy
- Greater risk of low birthweight, respiratory problems, third trimester bleeding, toxemia and mortality
- Anywhere from 45 to 94% of infants exposed to opioids in utero, including methadone and buprenorphine, can be affected by NAS
- Opioid exposure in pregnancy has also been associated with postnatal growth deficiency, neurobehavioral problems, and sudden infant death syndrome
41
How do you do the toxicology screening of newborns?
Urine - First urine from baby
- Doesn't give long term exposure data - last few days
Meconium - Detects from 2nd trimester
- Not always reliable
Hair- Detects from 3rd trimester
- Need 20-50 mgs of hair
- Used when CPS is involved
42
What are some signs of Neurobehavioral dysregulation in newborns?
Sensory processing:
- Hyper/hypo
- Visual auditory tactile
State Control/Attention:
- Liability
- Staring
- Irritability
- Gaze aversion
Autonomic Control:
- Respiration
- Gastrointestinal
- Skin temperature/color
Motor and Tone Control:
- Tremors
- Seizures
- Coordination Problems
43
What is the hallmark of neonatal withdrawal?
The hallmark of neonatal withdrawal is a striking disorder of movement or "jitteriness"
Also most common:
- GI problems - Vomiting, food intolerance
Respiratory SYmptoms - Rapid breathing, nasal flaring due to breathing difficulties
44
What are the clinical features of NAS?
- Autonomic over-reactivity - yawning, sneezing, mottling and fever
- Excessive or continuous high-pitched cry
- Tremor
- Excoriation - rub their chins, knees, elbows, nose and toes against blankets, sheets or clothing
Cerebral Irritation - a term used to describe extreme "perceived" pain that a newborn experiences which is of unknown
- Hypertonic and irritability
Difficulty nursing from a bottle or mother
45
What are other drugs causing infant withdrawal?
- Nearly all have some effect on the baby - licit and illicit
- Cocaine may cause some withdrawal, but the main symptoms in the baby are due to the toxic effects of the drug itself
- Other drugs, such as amphetamines and barbiturates, can also cause withdrawal
- Alcohol use causes withdrawal in the baby, as well as a group of problems including birth defects called fetal alcohol spectrum disorders (FASDs)
46
What are factors associated with clinical presentation?
Infant factors
- Male infants have been reported to have more severe NAS expression
Gestational age
- Preterm infants have less severe expression of NAS
- NAS measurement tools were designed for term infants
Environmental Factors
- Physical environment
- NICU care may increase NAS severity, while maternal rooming-in can reduce NAS severity
- Misinterpretation of or inappropriate responses to infant cues or insensitive handling can exacerbate NAS expression
47
When is the onset of withdrawal for methadone, heroin, and suboxone?
Methadone - 24-72 hours
Heroin - Within 24 hours
Suboxone - Within 48 hours
Infants are monitored for 7 days for signs of withdrawal because of rare cases of late onset
48
What is the assessment for neonatal abstinence syndrome?
Frequent assessment (every 3-4 hours) using standardized assessment tools.
Most widely used:
Finnegan Scoring System
- Scores are used to help quantify the severity of the withdrawal and they are used as a guide to start, wean and discontinue treatment
- A normal newborn can have scores as high as 8
- Anything greater than 8 requires treatment
- Examination of infant just as important as evaluation of scores as scores can be somewhat subjective
49
What is the non-pharmacologic management order?
-Decrease Environmental Stimuli
- Dim lighting
- Peaceful and Quiet environment
- Swaddle
- Pacifier
- Tactile Stimulation
- NICU care can exacerbate NAS severity, while maternal rooming-in can reduce NAS severity
50
What is the Eat, Sleep, Console (ESC) Approach?
Observational Assessment that Guides Tx
1. can the infant eat ≥ 1 oz per feed or breastfeed well?
2. Can the infant sleep ≥ 1 hour?
3. Can the infant be consoled within 10 minutes?
If all three criteria are met, discontinue interventions
If not -> increased non-pharmacologic interventions furst
Then pharmacologic treatment if needed
51
What is the relationship between breastfeeding and Medically Assisted Treatments?
- Newborn babies exposed to opioids or the medication for the opioid use disorder should breastfeed. They are encouraged to breastfeed - unless they have illicit drugs in their system.
- Studies report shorter hospital stays for breastfed infants
- "Promoting maternal-newborn contact, rooming-in, and breastfeeding may help to decrease the severity of NAS and the need for pharmacological treatment of NAS."
52
What are associated problems with infants with a diagnosis of NAS?
Some preliminary data suggest that infants with a diagnosis of NAS are more likely to need special education services in preschool and elementary school.
It is difficult to understand if other substances as well as the postnatal environment are significant factors.
- A study with children exposed to opioids found reduced regional volumes in many brain areas including:
- cortex, amygdala, basil ganglia
And reductions in head circumference.
53
What are the associated problems with women with SUD?
Women with substance use disorders experience subpar prenatal care, poor nutrition, chronic medical problems, poverty, and DV
Early problems w/ maternal-infant relationship -> negative effects of prenatal drug exposure
54
True or False: Doctors call for changes to laws that criminalize drug use during pregnancy
True.
25 states and the District of Columbia consider substance use during pregnancy to be child abuse
5 consider it grounds for civil commitment
55
What does the case of L.J.B in Pennsylvania say?
“The Pennsylvania Supreme Court held that a mother’s use of opioids while pregnant is not civil child abuse under the Child Protective Services Law (CPSL), which carries with it inclusion in a statewide database of child abuse perpetrators. Using statutory interpretation, the supreme court reasoned that the definition of “child,” under the CPSL does not include a fetus or unborn child, and a person is not a perpetrator of child abuse unless there is a “child” at the time of the act.”
56
What was the reasoning for case of L.J.B in Pennsylvania.
- "By bolding that drug exposure in utero is not child abuse, (not making the mother a registered child abuse), and emphasizing the importance of supporting has reaffirmed an important message about the goals of child welfare."
- "A contrary finding in this case could result in penalizing women for seeking prenatal care, medical services, or addiction treatment while pregnant"
- Collateral consequences - mother's name on a child abuse registry, which could significantly impact future employment, housing, and community participation
-"Punishing pregnant women for substance use may cause them to disengage from the health care system and make them less likely to seek prenatal care and substance use treatment."
- Researchers found that among births in states with punitive policies, the odds of neonatal abstinence syndrome were significantly greater both in the first full year following enactment and in subsequent years
- Disengaging from the health care system poses risks both for pregnant women and their infants
