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Part 1Opening remarksFire exitsCell phonesPaper work for Credit and for NarcanWebsite availability of presentationsIntro of dignitaries if presentOrder of the dayCASA Report and WHO report40milllion addicted80 million risky users at a cost of more than 600 Billion per yearMedication Assisted TreatmentCare Reform and ParityCommunity MobilizationQ&ALunchCurrent Trends in Substance UsePain Management Issues in Treatment SettingsVeterans Issues and Substance UseQ&A# PM Narcan Training for those interestedCASA Columbia Report40 million Americans addictedAbout 29 million being spent to treat80 million Americans risky usersNo direct funding for this group (except for SBIRT)Admissions aged 15 to 17 most frequently reported marijuana (71.9percent) or alcohol (17.7 percent) as their primary substance of abuse

About 14.3 percent of older adolescent admissions reported first using their primary substance of abuse at age 11 or younger, and over half (56.3 percent) reported first using their primary substance between the ages of 12 and 14

Almost one third (32.2 percent) of admissions aged 15 to 17 had been admitted to treatment at least once prior to their current treatment episode

Among older adolescent admissions, the most commonly reported principal source of referral to treatment was the criminal justice system (51.2 percent)From Feb 2012 SAMHSA report

6.3 6.0 5.7 6.3 5.7 6 5.4 4.8 5.2 6.0 5.0 5.0 5 4.4+ 4.4+ 4.6+ 4.1 3.8+ 3.9+ 4 3.4+ 3.4+ 4.3+ Percent Using in Past Month 4.1 3.1+ 2.7+ 2.6+ 2.4+ 3 1.9+ 2.0+ 2 50 to 59 50 to 54 55 to 59 8 7 7.0 7.2 6.7 1 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Past Month Illicit Drug Use among AdultsAged 50 to 59: 2002-2011The Centers for Disease Control and Prevention has classified the misuse of these powerful painkillers as an epidemic, with 1.3 million emergency room visits in 2010, a 115% increase since 2004. Overdose deaths on opioid pain relievers surpassed deaths from heroin and cocaine for the first time in 2008. PRESCRIPTION PAIN KILLERS

Suffolk County Preventing Misuse of Prescription Opioid Drugs 2012 . 2 Statistics show that 70% of children who abuse prescription drugs get them from family or friends. County Executive ManganoAdmissions for alcohol abuse have always represented the largest number of admissions, but have been steadily decreasing. The number of admissions for heroin and prescription drugs as a primary substance of abuse has increased over the last several years. Admissions for opioids alone have increased by 60% between 2007 and 2010. Admissions for prescription drugs including Xanax and OxyContin, and other opioids such as Vicodin and Percocet, have all increased across all the different services in Nassau County. There were 747 admissions in 2007, that number increased to 1,356 in 2010, an increase of 82%. Admissions for OxyContin alone increased 160% during the same time period. Admissions to Crisis Services, which represent the highest level of care in the county, for OxyContin increased 250% from 80 admissions in 2007 to 281 in 2010. Of particular concern is that the number of admissions of young adults in the 19-26 age groups has significantly increased. These admissions place even more importance on prevention efforts aimed towards the younger population still in middle and high school and to engage parents and communities in prevention activities.Nassau CountyIn Suffolk County, deaths involving opiates have risen since 2004.

The number of deaths in which non-heroin opiates played a part in the cause of death increased by 70% between 2004 and 2011.

The incidence of one opiate in particular, oxycodone, more than tripled between 2004 and 2011.

Oxycodone appears in nearly one-third of all reports and fentanyl in nearly one-quarter of the reports. Suffolk County DataSILK ROAD As of 2012, annual sales are estimated to be 22 million US dollarsBuyers and sellers conduct all transactions with Bitcoin, a crypto-currency that can provide strong anonymity.[11]

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MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders.MEDICATION ASSISTED TREATMENT(MAT)

Improve survivalIncrease retention in treatment Decrease illicit opiate use Decrease hepatitis and HIV seroconversion Decrease criminal activitiesIncrease employmentImprove birth outcomes with perinatal addicts Potential BenefitsMedications for Alcohol DependenceNaltrexone (ReVia,Vivitrol,Depade)Disulfiram (Antabuse)Acamprosate Calcium (Campral

Medications for Opioid DependenceMethadoneBuprenorphine (Suboxone Subutex)NaltrexoneOther Agents BACLOFEN BUPROPION VARENICLINE ONDANSETRON (Zofran) NALMEFENE

Baclofen, is a GABA-B receptor agonist (GABA is the predominant inhibitory neurotransmitter in the brain). In alcohol and opiate withdrawal, one can see a heightened level of vital signs and a highly excitable state. With agonist properties similar to an inhibitory neurotransmitter, it is hoped that this medication will reverse some of the signs and symptoms of withdrawal in the alcohol and opiate dependent patient. Initial alcohol research has found that Baclofen can reduce voluntary intake of alcohol by rats, decrease alcohol craving and alcohol withdrawal syndrome intensity in alcohol dependent patients ( Am J of Med 2002 - a small study using 10 mg as an initial dose and 10 mg every 8 hours for 30 days in 5 patients). Work presented in the Alc Clin Exp Res issue (2000) supported Baclofen as reducing alcohol intake due to its anti - craving properties. In opiate research, Baclofen J Clin Pharm Ther (2001), 62 opiate dependent patients were treated with either Baclofen 14-day, double blind trial.There is also research using Baclofen for cocaine dependence, looking at the GABA modulation of cocaine self-administration and Baclofen's ability to reduce this. As published in the Dec. 15 edition of the Journal of Clinical Psychiatry, the randomized, double-blind study, found that Baclofen used in conjunction with substance abuse counseling significantly reduced cocaine use in recovering addicts compared to placebo coupled with counseling. UCLA Neuropsychiatric Institute, Dec. 15, 2003

Bupropion was originally marketed as an antidepressant Bupropion was found to aid in tobacco cessation therapy and it was approved for use by the FDA in 1997.

The mechanism of action in the smoker is not known, though it may work through the dopaminergic and adrenergic systems Negative mood states certainly are a component of nicotine withdrawal and the usefulness of this antidepressant may lie at least partially in this domain.

Bupropion has been successful as a cessation modality with 27 percent abstinence at six months compared to 16 percent in the placebo group as reported by Hurt et al.

18Alcohol dependence and tobacco dependence are frequently co-morbid conditions. It has been reported in rodent studies that varenicline reduced alcohol intake.

Ericson (J Pharmacol Exp Ther. 2009; 329(1):225-30)

Mckee (Biol Psychiatry. 2009; 66(2):185-90)

Varenicline and AlcoholEricson (J Pharmacol Exp Ther. 2009; 329(1):225-30) showed that varenicline exhibits properties with respect to its interaction with ethanol and nicotine in the brain reward system that may be beneficial for treating patients with alcohol dependence with (and possibly also without) concomitant nicotine dependence.

Mckee (Biol Psychiatry. 2009; 66(2):185-90) looked at varenicline in non-alcoholic but heavy drinking smokers. In a double-blind, placebo-controlled trial using varenicline vs. placebo in 20 subjects. Following 7 days of medication pretreatment, participants were first administered a priming dose of alcohol and subjective, and physiologic responses were assessed. A 2-hour alcohol self-administration period followed during which participants could choose to consume up to 8 additional drinks. The results showed that varenicline significantly reduced the number of drinks consumed compared to placebo and increased the likelihood of abstaining from any drinking during the self-administration period. Following the priming drink, varenicline attenuated alcohol craving and reduced subjective reinforcing alcohol effects (high, like, rush, feel good, intoxicated). Adverse events associated with varenicline were minimal.

19ONDANSETRON (Zofran)

Used to treat nausea in chemotherapy patients.Used to treat nausea in chemotherapy patients.

Appears to work through the serotoninergic system.

Serotonin is implicated in alcoholic-drinking behavior, especially in regard to the serotonin3 receptor and its effect on dopamine.

In alcoholics, it is possible that reduced serotoninergic function results in a heightened sensitivity of the serotonin3 receptor.

If this receptor could be blocked, there would be a decrease in alcohol-induced dopamine release, resulting in a decrease in alcoholic-drinking behavior.

20Opioid antagonist similar to naltrexone

Recent research demonstrated that it may have advantages to naltrexone because there is: no risk of liver toxicity, higher biologic activity than naltrexone longer acting.

Dr. Barbara Mason's research showed that patients treated with nalmefene during a 12-week trial were 2.4 times less likely to relapse from alcohol than those treated with a placeboNALMEFENEIbogaine and its derivatives show promise at blocking withdrawal symptoms and drug cravings long enough to provide an opportunity for extending behavioral treatment, thereby improving treatment outcomes.

IbogaineCan LSD cure alcoholism? Trials show 59 per cent of problem drinkers improve after a single dose.

A hallucinogen with both psychedelic and dissociative properties, the substance is banned in some countries; in other countries it is being used to treat addiction to methadone, heroin, alcohol, cocaine, methamphetamine, and other drugs. Derivatives of ibogaine that lack the substance's hallucinogenic properties are under development.[1]22Kudzu root, flower, and leaf are used to make medicine. It has been used in Chinese medicine since at least 200 BC. As early as 600 AD, it was used to treat alcoholism Sensory imageryAcupuncture

OLD TREATMENTS

Mindfulness training

The mechanism for this is not yet established, but it may have to do with both alcohol metabolism and the reward circuits in the brain.Kudzu root compounds can affect neurotransmitters (including serotonin, GABA, and glutamateKudzu has traditionally been used as a remedy for alcoholism and hangover in China. The root was used to prevent excessive consumption, while the flower was supposed to detoxify the liver and alleviate the symptoms afterwards. Some TCM hangover remedies are marketed with kudzu as one of their active ingredients. This has also been a common use in areas of the Southeastern United States.

Sensory imagery is a powerful tool for inducing craving because it is a key component of the cognitive system that underpins human motivation. The role of sensory imagery in motivation is explained by Elaborated Intrusion (EI) theory. Imagery plays an important role in motivation because it conveys the emotional qualities of the desired event, mimicking anticipated pleasure or relief, and continual elaboration of the imagery ensures that the target stays in mind. We argue that craving is a conscious state, intervening between unconscious triggers and consumption, and summarise evidence that interfering with sensory imagery can weaken cravings. We argue that treatments for addiction can be enhanced by the application of EI theory to maintain motivation, and assist in the management of craving in high-risk situations.

Mindfulness training, which is based on ancient Buddhist models of human suffering, has recently shown preliminary efficacy in treating addictions

23Studies focusing on gamma-aminobutyric acid receptors voltage-gated ion channels transcranial magnetic stimulation dopamine D3 receptor (D3R) -type peroxisome proliferator-activated receptors (PPAR) (clofibrate)

New TreatmentsNeuropsychopharmacology ReviewsNeuropsychopharmacology Reviews (2012) 37, 163177; doi:10.1038/npp.2011.216; published online 26 October 2011Substance AbuseNovel Therapeutic Strategies for Alcohol and Drug Addiction: Focus on GABA, Ion Channels and Transcranial Magnetic StimulationGiovanni Addolorato1, Lorenzo Leggio1,2, F Woodward Hopf3, Marco Diana4 and Antonello Bonci5,6,71Institute of Internal Medicine, Catholic University of Rome, Rome, Italy2Brown University Medical School, Department of Behavioral and Social Science, Center for Alcohol and Addiction Studies, Providence, RI, USA3Department of Neurology, Ernest Gallo Clinic and Research Center, University of California, San Francisco, CA, USA4Department of Drug Sciences, G Minardi Cognitive Neuroscience Laboratory, University of Sassari, Sassari, Italy5NIDA Intramural Research Program, Baltimore, MD, USA6Department of Neurology, UCSF, San Francisco, CA, USA7Solomon H Snyder Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, MD, USACorrespondence: Dr A Bonci, NlDA Intramural Research Program, Baltimore, MD, USA; Department of Neurology, UCSF, San Francisco, CA, USA; & Solomon H Snyder Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, MD, USA. Tel: +1 44 3740 2463, Fax: +1 44 3740 2855, E-mail: antonello.bonci@nih.gov; antonello.bonci@ucsf.eduReceived 8 March 2011; Revised 8 July 2011; Accepted 27 July 2011; Published online 26 October 2011.

Clofibrate prevented the acquisition of nicotine-taking behavior in naive animals

24Randomized controlled trial of a novel cannabis use intervention delivered by telephone

AimsTo evaluate the efficacy of a telephone-based intervention consisting of four sessions of motivational interviewing (MI) and cognitive behavioral therapy (CBT) designed to assist individuals to reduce their cannabis use and related problems.

ConclusionsA brief course of motivational interviewing plus cognitive behavioral therapy delivered by telephone can help to reduce cannabis dependence and promote abstinence in the short term.Peter J. Gates1,*, Melissa M. Norberg1, Jan Copeland1, Erol Digiusto2Article first published online: 10 AUG 2012AimsTo evaluate the efficacy of a telephone-based intervention consisting of four sessions of motivational interviewing (MI) and cognitive behavioural therapy (CBT) designed to assist individuals to reduce their cannabis use and related problems.

.FindingsIntervention participants reported greater reductions in dependence symptoms [P