Addiction medicine

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addiction mechanics, a neurobiological understanding focussing on alcohol addiction.....

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  • 1. Addiction-Medicine: AnOverviewRamkumar G. S. MDDept. of Psychiatry.

2. Slide 2 of 25Over view of presentation Why do people take drugs and why some ofthem become addicted? Neurobiological understanding of addiction. Alcohol Use Disorder. Treatment processes in deaddiction care/drugs used/psychotherapy. 3. Slide 3 of 25Why use drugs? Is it simply a search forfun?Image courtesy: Google images 4. Slide 4 of 25Why use drugs? many people also take drugs to feelcomfortably numb. Feel pleasantly drowsy. Feel full of energy and confidence. As a self administered medicine for negativeemotional states, aversive states like drugwithdrawal Feel normal Peer pressure 5. Slide 5 of 25Why use drugs? Individual development (Thrill seekingpredispositions, impulsive temperament) Social background. Unidentified disorders of mood. Unopposed and chronic stress responses. Genetic predisposition. 6. Slide 6 of 25Why use drugs? In a Drug using career different motivationsmay become dominant at different point oftime. Different perspectives molecular, genetic,pharmacological, psychological, Social. 7. Slide 7 of 25Alcoholism Substance use. Problematic use. Substance misuse. Abuse. Harmful use. AddictionDependence Spectrum 8. Slide 8 of 25 9. Slide 9 of 25Addiction/Dependence PHYSICAL vs Psychological Dependence Conditioning to Pathologicalneuroadaptation.. 10. Slide 10 of 25Neurobiology of addiction.Reward circuitryNeurotransmittersinvolved Dopamine,Endogenous opoids+ve reinforcement,compulsive drug seekingbehaviourPleasure seekingNeuroadaptive processan altered biologicalhomeostasisInvolvement of stresshormones like NYP andCRP-ve reinforcement,craving, tolerance,salience in drug usage 11. Neuroadaptation (+ve reinforcement) inChronic alcohol useSlide 11 of 25 12. Slide 12 of 25Mu opoid receptor 13. Neuroadaptation (-ve reinforcement) inChronic alcohol useSlide 13 of 25CRF/Glutamatetone isupregulatedNYP/GABAis downregulated.Alcohol is neuro inhibitory/depressant/ anxiolyticGlutamate is excitatoryGABA is inhibitoryCRF stress promotingNYP stress reducing 14. Changing pattern of motivation in a drugusing careerSlide 14 of 25 15. Slide 15 of 25AUD Heterogenous disorder eg. Type 1 and 2 Course: remission and relapse. Disease management approach rather thanthe cure approach in acute illness. Chronic illness needing long term longintensity treatment with brief high intensitytreatment for relapse and on the front end ofthe abstience process. 16. Slide 16 of 25Treatment approachDetoxification Pharmacologicaldetoxification treatment.Psychological Treatment.Pharmacology forreversing pathologicalneuroadaptation.Maintenance treatment 17. Containing the withdrawal response bydetoxificationSlide 17 of 25 Withdrawal symptoms arisewhen alcohol is being usedregularly and withdrawn rapidly. Excitatory glutamatergic tone. Delerium tremens Treatment is via sedation withadequate dosage ofbenzodiazepines, Thiaminesupplementation. 18. Reversing pathological neuroadaptation. With appropriate help, withdrawing fromalcohol is not the dependent drinkerss maindifficulty. The main difficulty is avoiding relapse intofurther problematic drinking or dependence. Differentiation of physical vs psychologicaldependence as therapeutic implications.Slide 18 of 25 19. Slide 19 of 25Drugs. 20. Slide 20 of 25Psychological therapy Motivational enhancement therapy.(MET) 12 Step facilitation program/ AA group. Relapse prevention. Craving management. Cognitive Behavioural therapy ( dealing withhigh risk situation, contingency management,community reinforcement techniques) Social skills training, Behavioural contracting,Behavioral Family therapy. 21. MET (stages of changer model- Miller)Slide 21 of 25 22. Slide 22 of 25Off label drugs in AUD Topiramate Buspirone Fluoxetine Ondansetron Baclofen 23. Slide 23 of 25 24. Slide 24 of 25 25. Slide 25 of 25Summary. Addiction which sets in because of the conditioningeffects of the self reinforcing reward sensationsassociated with substance use. It is maintained by the underlying neuro-adaptiveprocess that sets in. There are biological, psychological and socialvulnerabilities that directly influence it in addition tothe environment. Effective treatment takes on a bio-psycho-social-spiritualapproach. Matching treatment to the person. 26. Slide 26 of 25Sources: Oxford textbook of Psychiatry. Medscape Psychiatry, July 22,2014, What isAddiction? by Denck E Vergne MD Psychiatric Times, Nov 2, 2012, Advancesand challenges in treating alcoholdependence by Hellen M Pattinatti PhD Other internet resources.