Di5PR1&2

Di5PR1.pdf

4/16/2023

This presentation answers: ● What part of the brain is involved in addiction? ● What neurotransmitters are involved in addiction? ● What is the difference between dependence and abuse? ● What is the difference between withdrawal and addiction? ● What is the meaning of dual diagnosis? ● Describe what is Medication-Assisted Treatment (MAT)? What medications are used in MAT? ● What medications are used in the management of SOBRIETY? ● Differentiate medications used in the management of CRAVING. ● **How do you plan on becoming an X Waiver provider? ● **How do you plan on becoming a CARN provider?

**Resources that offer this class will be shared

What part of the brain is involved in addiction?

Disruptions in three areas of the brain are particularly important in the onset, development, and maintenance of substance use disorders:

(1) Basal ganglia (2) Extended amygdala (3) Prefrontal cortex

(US Department of Health and Human Services)

Why? These disruptions:

(1) enable drug-associated cues to trigger substance seeking

i.e., they increase incentive salience, or the want for drug cravings (Robinson et al.)

(2) reduce sensitivity of brain systems involved in the experience of pleasure or reward, and heighten activation of brain stress systems

In other words, your brain increasingly needs higher doses to experience the same pleasurable effect.

(3) reduce functioning of brain executive control systems, which are involved in the ability to make decisions and regulate one’s actions, emotions, and impulses.

What neurotransmitters are involved in addiction?

Quick review ● A neurotransmitter (NT) is released from a

giving (presynaptic) cell and swims across the synaptic space. It attaches itself to a receptor on a receiving (postsynaptic) cell.

● Depending on the type of neurotransmitter, the postsynaptic cell is commanded to perform an action, or not perform an action.

● Once it has carried out its job, the NT is discarded or recycled. It is either broken down by enzymes or taken up by a transporter molecule and returned to the presynaptic vesicle that released it for reuse.

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Dopamine

● Dopamine is the chief neurotransmitter in the brain reward pathway. ● After dopamine has been released into a synapse, it normally doesn't remain there long; the

presynaptic neuron's transporter sucks it right back up. ● Addictive drugs all increase brain levels of dopamine. ● Drugs prolong dopamine’s stay in the synapses and thus prolonging its pleasurable sensations. ● Some drugs interfere by forcing the presynaptic cell to release more than the usual amounts of

dopamine, others by preventing re-uptake by the transporter; some may even do a little of both. ○ Cocaine, for example, imitates dopamine so well that it can bind to the transporter and block

dopamine reuptake. ○ Amphetamines reverse the transporter's normal function, preventing re-uptake while also

using the transporter to pump additional dopamine into the synapse from the presynaptic cell.

(Powledge)

Mesolimbic Dopamine Pathway

The mesolimbic pathway projects from the VTA (Ventral Tegmental Area) to several limbic structures

It forms extensive connections with the frontal lobes, and is thought to be important to a wide range of functions, such as motivation, emotion, and executive functions.

It’s one of the main dopamine pathways of the brain.

(Powledge)

2-Minute Neuroscience: VTA & Mesolimbic Dopamine Pathway

https://youtu.be/4t1EsfhPBTk

What is the difference between dependence and abuse?

Substance dependence is when the body adapts to a substance’s presence and needs more in order to achieve the same effects experienced compared to when the drug was first used.

Dependence on a substance occurs after exposure to it over time. If the substance use is suddenly stopped, the user experiences withdrawal symptoms.

A person can develop both a psychological and physical dependence on a substance, or a physical dependence only.

Substance abuse refers to a pattern of behavior where a person uses mind-altering substances in amounts or in ways that are harmful to themselves or other people.

(US Department of Health and Human Services)

What is the difference between withdrawal and addiction?

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Common physical drug withdrawal symptoms include:

● Excessive sweating ● Dizziness ● Insomnia ● Vomiting ● Constipation ● Diarrhea ● Aches and pains ● Drug cravings ● Loss of appetite ● Lethargy ● Restlessness ● Chills ● Cold and flu-like symptoms ● Tremors

● Fever

● Anxiety ● Depression ● Panic attacks ● Paranoia ● Impaired cognitive ability ● Impaired concentration ● Racing thoughts ● Mood swings ● Heightened emotions ● Lack of motivation ● Irritability ● Short term memory loss

(US Department of Health and Human Services)

Common psychological drug withdrawal symptoms include:

Signs and symptoms of addiction include:

Physical

● Inability to sleep or consistently waking up throughout the night

● Loss of or increased appetite ● Weight loss or gain ● Bloodshot eyes ● Sweating ● Nausea and vomiting ● Runny nose or frequent rubbing of the nose ● Deterioration of physical health ● Irregular heartbeat ● Slurred speech

● Headaches ● Lack of hygiene ● Presence of needle marks ● Shakiness or tremors ● Diarrhea

Behavioral

● Change in overall attitude with no identifiable cause

● Missing school or work ● Decline in performance at work or school ● Not fulfilling roles or responsibilities ● Hyperactivity ● Lethargy ● Change in activities or hobbies ● Change in friends ● Declined participation in things that were once

enjoyed

● Engaging in risky behaviors ● Poor coordination ● Increased conflict with others ● Social withdrawal or isolation ● Secretive or suspicious behavior

(US Department of Health and Human Services)

Signs and symptoms of addiction include:

Cognitive

● Psychosis ● Paranoia ● Difficulty paying attention ● Delayed thinking ● Confusion ● Forgetfulness ● Detachment from reality

● Hindered decision-making abilities ● Hallucinations ● Delusions ● Inability to reason

Psychosocial

● Depressed mood ● Increased anxiety ● Inability to experience pleasure ● Lowered self-esteem ● Oversensitivity ● Moodiness or irritability ● Drastic mood swings

● Agitation

(US Department of Health and Human Services)

What is the meaning of dual diagnosis?

Dual diagnosis refers to one or more diagnosed mental health problems occurring at the same time as problematic drug and alcohol use.

A dual diagnosis condition can include:

● a mental health problem or disorder leading to or associated with problematic alcohol and/or other drug use

● a substance use disorder leading to or associated with a mental health problem or disorder

● alcohol and/or other drug use worsening or altering the course of a person’s mental illness.

Most importantly, a dual diagnosis needs an integrated approach to assessment and treatment in both specialist mental health and alcohol and other drug services.

(Department of Health. Victoria)

What is Medication- Assisted Treatment (MAT)?

What medications are used in MAT?

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https://www.tullyhill.com/mat-at-tully-hill-our-use-and-perspective/

Medication-Assisted Treatment (MAT)

● “Medication-assisted treatment (MAT) is the use of medications in combination with counseling and behavioral therapies for the treatment of substance abuse disorders, or SUD (U.S. Food & Drug Administration).”

● The FDA has approved several different medications to treat alcohol use disorders (AUD) and opioid use disorders (OUD).

● These medications relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body. Medications used are evidence-based treatment options and do not just substitute one drug for another (Substance Abuse and Mental Health Services Administration).

Approved Medications for MAT

In alcohol use disorders (AUD):

● Acamprosate (Campra) ● Disulfiram (Antabuse) ● Naltrexone (Vivitrol oral or IM,

Revia)

In opioid use disorders (OUD):

● Buprenorphine (Buprenex) ● Methadone ● Naltrexone

What medications are used in the management of sobriety?

Sobriety management

Acamprosate (Campra)

Naltrexone (Vivitrol oral or IM, Revia)

Disulfiram (Antabuse)

Ondansetron (Zofran)

Heldt

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Heldt Heldt

Ondansetron (Zofran), an anti-nausea medication, is said to lower drinking and cravings. It may also be suitable for individuals with biological predisposition to early-onset AUD.

● Side effects: commonly causes headaches, constipation, and tiredness. ● Ondansetron is a 5-HT3 antagonist. 5-HT3 antagonism has been shown to

block alcohol-seeking behaviors and reduce ethanol-associated dopamine concentration in the nucleus accumbens.

● Clinically, ondansetron may be particularly effective in combination with naltrexone.

(Burnette et al.)

Differentiate medications used in the management of cravings.

Craving management

Buprenorphine (Buprenex)

Methadone

Naltrexone

Heldt

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Heldt Heldt

How do you plan on becoming an X Waiver provider?

What is an X Waiver? An “X waiver” refers to the Drug Addiction Treatment Act (DATA 2000) “waiver” legislation that authorized the outpatient use of buprenorphine for the treatment of opioid use disorder. This waiver, along with the associated 8 hour (physician) or 24 hour (APP) training was previously required for any provider prescribing buprenorphine.

As of January 2023, prescriptions for buprenorphine only require a standard DEA registration number.

● The X waiver is no longer required for any prescriber to treat patients with buprenorphine for opioid use disorder.

● No longer any limits or patient caps on the number of patients a prescriber may treat for opioid use disorder with buprenorphine.

● Congress also mandated new DEA applicants or with DEA renewal to take 8 hours of buprenorphine prescription training as a one time education effective June 2023.

(Center for Addiction Medicine and Policy)

Buprenorphine prescription training class

Per Congress, we need 8 hours of training to apply for or renew our DEA number. This is a one time only class:

Providers Clinical Support System: https://pcssnow.org/medications-for-opioid-use- disorder/waiver-training-for-nurses/

The American Psychiatric Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

How do you plan on becoming a CARN provider?

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What is a CARN provider?

The Certified Addiction Registered Nurse (CARN) is for RNs who have a minimum of 2,000 hours (one year) of nursing experience related to addictions as an RN.

The Certified Addiction Registered Nurse – Advanced Practice (CARN‐AP) is for RNs who hold a Master’s degree in Nursing. For both certifications, nurses may work in a variety of positions including clinical, administrative, teaching, private practice, consulting, counseling, or research roles that are addiction related.

Applications are found on:https://www.ancbonline.org/

(Addiction Nursing Certification Board)

What are the CARN-NP requirements?

1. RN license 2. Master’s degree 3. A minimum of 500 supervised hours in advanced clinical practice. These hours must be direct client contact hours

spent working with individuals and families impacted by addictions and/or dual diagnoses. Hours must be obtained within the last four years to be considered. Hours may be earned during the candidate’s Masters’ program or post- Master’s

4. In addition to the 500 directly supervised clinical hours described above, the candidate must have a minimum of 1,500 hours of nursing experience in addiction as an Advanced Practice Nurse (APN) within the last three years prior to submitting the examination application. The hours may have been worked in an administrative, teaching, private practice, consultation, counseling, or research capacity.

5. Candidates must have completed 45 contact hours of approved continuing education in addictions within the three years prior to submitting the exam application. Fifty‐one percent of the hours must be specific to addictions nursing, while the remaining hours must be related to addictions nursing (e.g., HIV/AIDS, hepatitis, pain management, etc.).

(Addiction Nursing Certification Board)

Works Cited @neurochallenged. “2-Minute Neuroscience: Ventral Tegmental Area.” @Neurochallenged,

neuroscientificallychallenged.com/posts/2-minute-neuroscience-ventral-tegmental-area.

Addiction Nursing Certification Board. “ANCB - Examination.” Www.ancbonline.org, www.ancbonline.org/Examination.

Accessed 17 Mar. 2023.

Burnette, Elizabeth M., et al. “Novel Agents for the Pharmacological Treatment of Alcohol Use Disorder.” Drugs, vol. 82, no. 3, Feb.

2022, pp. 251–74, doi:https://doi.org/10.1007/s40265-021-01670-3.

Center for Addiction Medicine and Policy. “All about the X Waiver – CAMP.” University of Pennsylvania,

penncamp.org/education/what-is-an-x-waiver-and-who-needs-one/#:~:text=What%20is%20an%20X%20Waiver. Accessed 17

Mar. 2023.

Department of Health. Victoria, Australia. “Dual Diagnosis.” Www.health.vic.gov.au, 29 May 2015, www.health.vic.gov.au/practice-

and-service-quality/dual-diagnosis

Heldt, Jonathan P. Memorable Psychopharmacology. Createspace Independent Publishing Platform, 2017.

Powledge, Tabitha M. “Addiction and the Brain.” BioScience, vol. 49, no. 7, July 1999, pp. 513–19,

doi:https://doi.org/10.2307/1313471.

Robinson, Mike J. F., et al. “The Incentive Sensitization Theory of Addiction.” Oxford Research Encyclopedia of Psychology, Jan.

2022, doi:https://doi.org/10.1093/acrefore/9780190236557.013.715.

Substance Abuse and Mental Health Services Administration. “Medications for Substance Use Disorders.” Www.samhsa.gov, 2023,

www.samhsa.gov/medications-substance-use-disorders.

U.S. Food & Drug Administration. “Information about Medication-Assisted Treatment.” U.S. Food and Drug Administration, 14 Feb.

2019, www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat.

US Department of Health and Human Services. “THE NEUROBIOLOGY of SUBSTANCE USE, MISUSE, and ADDICTION.”

Nih.gov, US Department of Health and Human Services, Nov. 2016, www.ncbi.nlm.nih.gov/books/NBK424849/.

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