Slide show of neuroanatomy, physiology, and behaivors of commonly abused prescription medications

1. Addiction to Commonly
Abused Medication
Dr. Selahattin Kurter, MD
Spectrum Healthcare, LLC
Westgrove Clinic, LLC
Diplomat American Board of Neurology and Psychiatry
Diplomat American Board of Addiction Medicine
Assistant Professor of Psychiatry,
Medical College of Wisconsin

2. Definition of Substance
Dependence
At least 3 of 7 symptoms, which must be met during a 12-month
period:
• Tolerance
• Withdrawal
• Longer duration of taking substance or use in greater quantities
than was originally intended.
• Persistent desire or repeated unsuccessful efforts to stop or
lessen substance use.
• A relatively large amount of time spent in securing and using
the substance, or in recovering from the effects of the substance.
• Work and social life impacted negatively because of substance
use.
• Continued substance use despite negative physical and
psychological effects of use.

3. Neuro-Anatomy of
Substance Dependence
-Neuro-transmitters
-Neuro-transmitter Pathways
-Anatomical Structures
-Specific Medication/Substance Effect on Neuro chemicals and
Pathways

4. Neurotransmitters
in Substance Dependence
• Dopamine:
– Reward/pleasure system. Vital and evolutionary advantageous
behaviors often involve dopamine such as sex and food, etc.
• Serotonin (5-HT):
– Modulation of anger, aggression, body temperature, mood, sleep,
sexuality, appetite
• Norepinephine
– “Stress hormone”
– Involved in alertness and arousal, and influences on the reward
system
• Endorphines
– Endogenous Opioids
– Produces sense of well being and analgesia. Secreted during
excitement, exercise and sex

5. Nucleus Accumbens

6. Nucleus Accumbens
• Major brain reward region. Many projections come from VTA
• Important role in reward, laughter, pleasure, addiction, fear,
and the placebo effect
• Almost every recreational substance causes a significant
increase in Dopamine in the Nucleus Accumbens.

7. VTA (Ventral Tegmental
Area)

8. VTA (Ventral Tegmental
Area)
• Part of the pleasure system, or reward circuit, one of the major
sources of incentive and behavioral motivation.
• Alcohol, Opioids, and Nicotine have a direct affect on VTA by
increasing Dopamine release to Nucleus Accumbens.
• May play a role in avoidance and fear conditioning due to
potential for motivating issues of security and emotions

9. Amygdala

10. Amygdala & Hippocampus
Amygdala:
• Involved in fear conditioning
• Emotional Regulation
• Primary role in the processing and memory of emotional
reactions
Hippocampus:
• Formation of new memories about experienced events
• Spatial orientation
• Stress affects this area significantly

11. Fig. 1: Human brain that highlights some of the main brain areas and
neurotransmitter pathways implicated in reward processes
Tomkins, D. M. et al. CMAJ 2001;164:817-821
Copyright ©2001 Canadian Medical Association or its licensors

12. How does it feel to get high?
• Euphoria
• “A sense of control”
• Less stress (lowers anxiety)
• More sociable
• More energy (get things done quicker)
• “I feel like Superman”

13. Cycle of Addiction?
• Describes cycle of craving, using, withdrawal, and desire to stay
“hooked” on the addicting substance. Both physiological and
psychological

14. What Medications are
Addicting?
• Many medications can be addicting
– Tolerance
– Withdrawal
– Significant “out of control” effects to person’s life
– Commonly the following medications have higher risk of
addiction:
• Opiod (pain medication)
• Benzodiazepines (anxiety medications)
• Stimulants (ADHD medications)

16. Dawn (Drug Abuse Warning Network) ER
Visits
High school opiate, cannabis, and alcohol
through 2006 (top down)

17. Hospital Admissions for
Heroin and Prescription
Opiod Painkillers
1995 2005 Increase
United States 242,381 317,011 30.79%
Illinois 5146 13,381 160.03%
Wisconsin 85 1694 1892.94%
Substance Abuse and Mental Health Services Administration (SAMHSA). Dept of Health and Human Services.
Treatment Episode Data Set (TEDS). 1995-2005. DASIS Series:S-37

18. Opiod use in Wisconsin
• Estimated 192,000 people in Wisconsin used prescription pain
relievers inappropriately in 20051
• In Wisconsin, rate of 18-25 year old age group using
prescription pain pills in past year (13.1%) was higher than
national rate of 11.8%2
1.SAMHSA. February 5, 2008. 2. SAMHSA. FEB 4, 2008 2. DEA. Briefs and backgrounds, drugs and drug abuse,
state fact sheet, Illinois. Feb 4, 2008.

19. Commonly Abused Opiod
Medications
• Morphine
• Hydrocodone (Vicodin)
• Hydromorphone (Dilaudid)
• Methadone
• Fentanyl (Sublimaze)
• Meperidine (Demerol)
• Oxycodone (Percodan)
• Oxycontin
• Propoxyphene (Darvon)
• Buprenorphine (Suboxone, Subutex)

20. Opiod Addiction Kills?
Risk of Respiratory Depression with Increasing Dose
70
60
50
40
30
20
10
O
A
E
c
e
n
g
d
o
p
s
t
f
i
0
Increasing Opioid Dose--->

21. Risk of Death or Danger
• 25% of Opiod addicts die in the first 5 years of
addiction
• 50% death rate every 5 years when IV heroin is
used
• Severe co morbidities occur with use:
– Endocarditis (heart valve infection)
– Hepatitis, HIV
– Tooth decay
– Cognitive effects
– Increase risk of criminality

22. Benzodiazepines
• Group of medications that are used to treat anxiety disorders,
muscle disorders, and social phobias
• They cause sedation, hypnotic effects, and muscle relaxation
• Can be snorting or used IV for a greater sedating effect
• More quicker acting and potent “Benzos” are more likely to be
abused and develop tolerance
Common Benzodiazepines (“Benzos”):
-Alprazolam (Xanax)
-Diazepam (Valium)
-Lorazepam (Ativan)
-Clonazepam (Klonopin)
-Temazepam (Restoril)

23. “Benzos”
• Long term use or misuse can cause or
worsen cognitive deficits, depression and worse
anxiety
• Abrupt discontinuation can lead to seizures and
death
• Withdrawal effects include tremors, agitation,
sweating, confusion, increased anxiety
• Moderate to severe withdrawal should be
managed medically (i.e. inpatient detox) to
prevent risk of death due to seizures

24. “Benzos”
• 10% of patients have protracted withdrawal syndrome, which
can persist for months to 1 year
• Overdoses usually do not lead to death unless it is mixed with
opioid or other sedatives (i.e. Alcohol)
• 80 percent of abuse is part of poly-drug abuse, most commonly
with opioid or alcohol
• 30-40% of Alcoholics have reported abusing “Benzos” some
time in their life
• 15% of heroin users report daily use of “Benzos”

25. Stimulants-Amphetamines
• Used to treat Attention Deficit Hyperactivity Disorder (ADHD)
and some types of depression
• Most potent forms derived from Amphetamine derivatives, such
as dextroamphetamine
• Causes increase in dopamine. Effects include increased focus,
increased heart rate, increased blood pressure, sweating,
increased cognitive functioning
• If abused or in high dosages, effects are euphoria, “confidence,”
grandiosity, irritability, increased sex drive, and weight loss
Common Stimulants:
-Adderall
-Adderall XR
-Dexedrin
-Ritalin

26. Stimulants-Amphetamines
• Toxicity occurs with repeated use
– Hypertension leading to stroke or brain hemorrhage
– Cardiac Arrhythmia leading to cardiac failure
• Abrupt discontinuation can lead to acute
depression and apathy in 50% of abusers
• 80% of amphetamine abusers report
hallucinations (visual and auditory)
• Chronic abuse of amphetamines may lead to
loss of dopamine regulation resulting in long
term cognitive and emotional imbalance

27. Treatment
• Necessity of individualized treatment
• Inpatient Detox, Day treatment, Outpatient
treatment
– Psychotherapy
• Group therapies (AA model, 12 steps)
• Individual therapy for drug addiction
– Medication Management
• Last 10 years great advancement in understanding of
neurobiology of addiction
• Evidence based treatments are augmentative to psychotherapy
• Must address both the biology and psychology of addiction

28. Questions?
Selahattin Kurter, MD
Email: spectrum_healthcare@yahoo.com