アルコール THC も含む 処方薬 : 抗不安薬 Benzodiazepines, 鎮痛剤 Opioids など アルコール アルコール一単位 :20mg で 1 単位 ( 日本 ) 14 mgで 1 単位 ( アメリカ ) BAC(Blood Alcohol Content) お酒の量 (ml)x
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1 第 17 回メンタルヘルスネットワーク会議概要 Substance/Alcohol Abuse and Dependence 日時 :2017 年 6 月 30 日場所 :NY 総領事館参加人数 :22 名会議進行 : 森真佐子氏 ( メンタルヘルスネットワーク副代表 ) 1. Addiction 101 真壁弘子氏 (Clinical Social Worker) DSM5 物質関連障害及び嗜癖性障害群の説明 アディクションとはある特定の物質や行動 人間関係を特に好む傾向 診断の基準 : 過去 12 か月において臨床的に重要な機能を破損したとされるとき 診断を確定 制御の破損 ( 例 : 当初意図したよりも過剰な摂取 または長期の摂取 ) 社会性の破損 ( 例 : 家族を省みなくなる 趣味の放棄 ) 危険な使用 ( 例 : 問題の存在に関わらず使用を継続する ) 医学的な判断 ( 耐性ができ 離脱症状がある ) 依存症への道のり 出会い 汎用期 友好期 発展期 熱愛期 破滅 出会いから破滅までの道のりを Addiction からのラブレターとして表現 ラブレターの文例も紹介される 摂取の方法 : 目的は快楽である 脳内の快楽中枢神経系に作用し 快楽伝達物質の分泌を増加 促進させる 脳内の快楽中枢神経系に届く速さは喫煙 静脈注射 鼻腔 粘膜 経口 皮膚の順である 田代まさし キース リチャーズ マコーレ カルキンなど薬物依存者の薬物使用前後の写真紹介 Upper: 覚醒作用をもたらす 覚せい剤 興奮剤 精神刺激剤を含む コカの木に含まれるアルカロイドが原料 使用後一週間で依存性が確立する シャブ と呼ばれるのは骨までしゃぶるから ヒロポン : かつての日本製の市販薬であり サザエさんでも紹介されていた カフェインやニコチンも精神刺激剤に含まれる Cocaine/Crack Cocaine の別名 :Blow, Bump, Candy, Coke, Rock, Snow Methamphetamine( アンフェタミン ヒロポン ) から生成された依存性の高いドラッグ 別名 :Crystal, Ice, Meth, Speed, Tina など 処方薬 :Ritalin, Adderall, Steroid など P&P:Party and Play ゲイの男性による ( 薬を使う乱交パーティ ) 現在では Tea Party などともよばれ Craig s List で参加者を募ったりする Downer: 鎮静作用をもたらす 脳の様々な領域で覚醒や刺激を減少または抑制して神経伝達の水準を低下させる薬物または化合物 抑制剤 中枢神経抑制剤
2 アルコール THC も含む 処方薬 : 抗不安薬 Benzodiazepines, 鎮痛剤 Opioids など アルコール アルコール一単位 :20mg で 1 単位 ( 日本 ) 14 mgで 1 単位 ( アメリカ ) BAC(Blood Alcohol Content) お酒の量 (ml)x[ アルコール度数 (%) 100]x0.8 ニューヨークでは0.08 以上で酒気帯び運転 :2 度目で逮捕 ハンドサニタイザーを飲むと BAC が 0.20 以上になる Long Island Ice tea: テキーラ ラム ウォッカ など 5 種類ミックスしたもので ウイスキーを 5 杯飲んだと同じアルコール摂取量 マリファナ : THC は脂肪質に付着するので 水を飲んでも排出されず 体の中から排出されるのが遅い 一服するだけで 陽性反応が 4 週間続く 体の中に脂肪質が多いのは脳 現在の 合成 マリファナ摂取は THC だけではなく いろんなケミカルを摂取することになる 8 週間体から抜けなかった人もいる 体の大きさ 筋肉の多さなどで 違ってくる ニューヨークでは Recreation 目的の使用は禁じられているが 医療用使用は認められている 別名 : Blunt, Grass, Joint, Mary Jane, Weed, Pot, Ganja, Herb, Reefer, Skunk( スカンクのように臭い ) 最近のマリファナは純正ではなくなってきている 処方薬 抗うつ剤 抗不安剤 Valium, Xanax, Ativan, Ambien, Lunesta, Xyrem ( 頓服として処方されることがおおい ) ケース : 日本人女性 抗不安剤の過剰摂取 現在は通院して断薬できた Date Rape Drug: 無防備な人を鎮静させ 行動不能にさせる ナイトクラブ バーなどで使用され 性的犯罪につながる可能性が高い 無味 無臭 無色 Dope: All Arounders: モルヒネ コデイン オキシコドン処方薬の鎮痛剤 精神安定剤 高い常習性を生む 年 50 万人以上がオピオイドの過剰摂取で死亡し 現在も毎日 91 人が死亡している (CDC) I save my neighbor s life: ニューヨーク州では 2006 年 4 月にオピオイド致死レベル過剰摂取者に Naloxone(Narcan) をトレーニングを受けた非医療関係者が投与できる条例を可決 脳神経系に作用して現実には存在しない異常な感覚 ( サイケデリック 幻覚体験 ) をもたらす 幻覚剤 PCP 別名 :Angel Dust, Love Boat LSD 別名 :Acid, Blotter, Yellow Sunshine
3 吸引剤 依存症体質 行動嗜癖 治療 : Ketamine: 家畜ペットの麻酔薬 デザイナードラッグ クラブドラッグ 市販咳どめ 自宅で生成できる MDMA は情報伝達機能を破壊し そのダメージは不可逆的である Peyote & Mushrooms 合成マリファナ : 従来のマリファナにコカインや PCP などの薬物を加えたもの 依存症になりやすい体質はないが 真面目 自己評価が低い 精神的に幼い 感情のコントロールが下手などが共通する ギャンブル インターネット ( ポルノ ゲーム ) などを含む アセスメント : 新久里浜式アルコール依存症スクリーニングテスト, DAST 使用者によって異なるニーズ : 女性 LGBT 移民 女性 : 日本人コミュニティーに知られたくない 日本人に診てほしくない 子供を連れていけない 使用者のニーズを知ることが大切 それぞれの患者さんのニーズを知ることが大切 質疑応答 Q: Family Dynamic と Addiction の関係は? A: 家族に対して教育と情報提供が大切である 使用者が厄介者の役割を背負っていることが多い 家族それぞれが自分の責任役割を果たすようにするべき ネゴシエーションによって バランスを立て直す作業が大切 中には自分のことはみたくない考えたくないという家族メンバーもいる そして厄介者にすることが多く そうするとそこから前に進まない Family dynamic への Intervention が大切 親が使っているのでやめられないなど 家族からの薬物使用に対するプレッシャーが存在する しかし親は自分の子への言動などを変えようとしない 世代を超えた薬物依存が存在する 薬物使用があるのが自然な家族環境があり 困難があったときは薬物に頼ることを子供時代から学んでしまう だから Substance Abuse は世代を超えて続いていくように思う 例えば 癇癪を起すと祖母がブランディーをくれた 等 Nature vs. Nurture: 双子の研究が示すように 遺伝的影響もあるが 親が使用していたから反面教師で使わないようにしているという例もある 全体的にイタチごっこの感も払拭できない アルコール オピオイドの歴史は古く 許容されている文化背景が存在するのも確かである 痛みに使うと痛みへの耐性が減る CBT Motivational Interviewing が効果があるように感じる 患者に回復したい気持ちが強くないとどんな治療も効果はない 回復したいというところまで持っていければ 8 割方の治療が済んだと思っていい 30 年ぐらい薬物を使ってなくても再発
4 したりする場合もある 自助グループも効果的である Methamphetamine (Crystal Meth) を乱用 依存したゲイ男性には CMA(Cristal Meth Anonymous) が強力である ストレスを感じたらバーに行くではなく それに置き換わる行動が効果的である 薬物はライフスタイルなので グリーフセラピーも効果的である 自分自身の社会生活にはマイナスだったけど 楽しみ 意味があったと一区切りおかせる グリーフプロセスをしないと治療が効果的でない アディクションからのラブレターに対して 薬物に対するさよならレターを書かせるのも効果的である そして レターをかけない人は再発する可能性が高い Q: DV と Addiction の関連は? A: パートナーから薬物を勧められて使用をする女性が多い 自分が回復するとパートナーと別れないといけない状況になる また薬物乱用と DV のかかわりは深い トラウマもあるので 薬物カウンセリングだけでは不十分である その場合 他のプロフェッショナルとの協力が治療に必要である 中身がぽっかり空いている人も数多い 心理的に何がぽっかりしているのかを把握し 個人個人のニーズに合ったカスタム化した治療が必要である 2. Pharmacological Approaches to the Treatment of Substance Use Disorders Dr. Andrew Chen (Hofstra Northwell School of Medicine Psychiatry,Associate Professor) Medication Assisted Treatment (MAT) is the use of medications in combination with counseling and behavioral therapies including social services, medical services, psychosocial services, and medication: Medication alone cannot solve the disorder. Myths about MAT for Substance Use Disorders (SUD) o You just trade one drug addiction for another drug addiction? NO! Research shows the combination of MAT and behavioral therapies has higher success rate for treating SUD o MAT is only for the short term No! Research shows that patients on MAT for 1-2 years have greatest rate of longterm success. o MAT increases the risk for overdose in patients No! MAT actually helps to prevent overdosing from occurring. Most people with addiction are not receiving MAT; Less than 1/3 people are receiving MAT Strategies for SUDs o Agonist/ Partial Agonist (Replacement/Substitution) o Antagonist (Blockade) o Aversive (positive punishment) o Correction of underlying disorders such as depression, anxiety, etc. Not all SUD for which FDA approved medications are available o For Opioids, Alcohol, Nicotine, we have treatment medications. Opioid Opioid use disorder: National Epidemic o Majority of OD deaths >60% involve an opioid o Since 1999, opioid OD deaths quadrupled
5 o From , more than half a million people died from drug overdose. MAT for Opioid Use Disorder o Methadone (full agonist), LAAM (no longer available due to arrhythmia), Buprenorphine (partial agonist: does not induce the full effect), Naltrexone (opioid antagonist), and Naloxone (opioid antagonist, short quick action). Full Agonist (Heroin, Methadone), Partial Agonist (Buprenorphine), Antagonist (Naltrexone and Naloxone) Heron VS Methadone o Heroin: concentration goes up very quickly (high) but quickly drops and feels sick (withdraw). When it goes high and low so quickly, people crave more. o Methadone: long half-life, it does not go high or low, stay in the same range (Comfort Zone). Methadone (Full Agonist) o In NY and NJ, patients need to go to a special clinic ( methadone clinic ) o Metabolized by 3A4 enzyme o 3A4 enzyme Inducers: Decreases methadone level, may precipitate withdrawal: rifampicin, phenytoin o 3A4 enzyme Inhibitors: Increases methadone level, increases risks of overdose: cimetidine, ciprofloxacin o Monitoring EKG: Prolong QTc with risk of Torsades de Pointes o Respiratory Depression: Can be a side effect at any dose o No 3Bs: Benzos, Barbiturates, Booze should not mixed with methadone. o Routine UTOX (urine toxicology screen) Buprenorphine (Partial Agonist with strong affinity to the mu-opioid receptor) o has a ceiling effect: does not feel high and is safe o Has slow onset and longer duration of action o Can be prescribed in an office not like methadone special clinic which reduces lot of stigma o Sublingual: absorption is much faster o Two formulations available: Buprenorphine only and the mix of Buprenorphine and Naloxone which keeps people from injecting because it won t give them high o You need to wait for previous drugs (heroin, methadone, etc) are excreted from the body. They need to be totally abstinent as they compete for the same receptor. When they come to the office, they are at a moderate withdrawal state. o Induction phase: Requires abstinent 24 hours or longer. Can be done outpatient. Give only 2 mg and evaluate withdrawal symptoms every 2 hours. If ok, patient can go home. If not, increase dosage up to 8 mg, then evaluate in 2 hours. o Stabilization phase: Psychosocial intervention is important Target daily dose 16mg/day (90% opioid receptor occupancy) up to 32 mg/day o Maintenance phase: 2-3 months, some people years. Function is important rather than taking med or not. No 3Bs, UTOX, LFT (Liver Function Test), EKG Make sure they take medication. It has a street value o Forms: Buccal film, film, tablet, sublingual tablet, implant
6 Implants that last for 6 months, cost $5000 Naloxone (Antagonist = totally block the receptor and block the euphoric effect) o Short acting, prevent OD. Let them take nasally, emergency use to save lives keeping from overdosing Alcohol Disulfiram (Antabuse) o Only for someone who is highly motivated. It causes severe reaction when taking alcohol (aversion) o Metabolized in liver LFT first 3 months, then quarterly Naltrexone (Revia): o Takes away pleasure and craving of drinking and makes alcohol less appealing o Competitive opioid antagonist o Work on reward system (opioid-dopamine cascade is the target of naltrexone) o Hepatotoxic Acamprosate (Campral) o Reduction in glutamate release, facilitate GABA o Opioid Antagonist, GABA receptor agonist o Metabolize through kidney, so good for patients with severe liver disease Other medications (off label): o Topiramate: seizure medication o o Clonidine (alcohol withdrawal) Medication for co-occurring psychiatric symptoms such as anxiety may work to treat alcohol dependency Nicotine Tobacco use is the leading cause of preventative death in the US. Pharmacological approach o Varenicline (Chantix: nicotinic receptor partial agonist) o Nicotine Replacement therapy (NRT) o Bupropion, o Mix of NRT and Bupropion Bupropion: Wellbutrin, Zyban o Help people reduce the craving, work on reward system o Pregnancy category (Class C) o Should not give to people with seizure disorder, eating disorder, MAOI use in past 2 weeks Varenicline (Chantix) o Partial agonist (rising star of psychiatry!): reduces the pleasure of smoking o Produces less effects of dopamine release, which makes cigarette smoking less desirable o Combination with fake cigarette maybe helpful: psychosocial intervention o Not recommended for use with NRT (may increase nausea and side effects) o Neuropsychiatric side effect: depression, nightmares o Good success rate. Among 3, Chantix is highest. Patch and pills are easier Nicotine Patch (Nicoderm) o Dose according to amount smoked Nicotine gum, inhaler, nasal spray Personalized medicine is in infancy state: but it will be in a form of medicine in the future
7 Q&A Q: What s the best treatment for alcohol dependency? A: CBT and MAT combination is more effective. Treatment goal may not necessarily abstinence. Goal is drinking in a safe range. Men no more than 4/day, 14/week, women 3/day, 7/week. CBT and Naltrexone are equally effective by my research. Some genetic markers are related to effectiveness of the medication. In one of my studies, 2/3 participants have grad degree, which is different from stereotype of alcoholics. Doctors and lawyers have good success rate because their license would be revoked. For teenage, the same medication can be used but they need psychoeducation for binge drinking and peer pressure. Family focused treatment is also important. Family issues need to be worked on as drug problem is often just one of issues. People stayed with medication (MAT) compared to people stopped MAT have better prognosis. People may need to stay on MAT longer. 閉会の挨拶 : 斎藤恵真氏 ( メンタルヘルスネットワーク代表 ) Dr. Andrew から薬物に関して詳しい情報 真壁さんから臨床の経験が聞けて バランスが良かたと感じる 多くのメンタルヘルスに関わる人々が参加して意義ある会であったと思う 以上は 表西恵氏 (Counseling Psychologist) による議事録からの抜粋
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参考資料 ICD-11 β 版和訳改訂案 和訳の候補 1 候補 2 候補 3 は 採用したい順としています 担当 原文 (4 月 25 日 /8 月 19 日 /2017 年 4 月 7 日現 在 ) 和訳候補 1 和訳候補 2 和訳候補 3 薬物 依存関連 アルコール学会 担当 Disorders
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Title 泌尿器科領域に於ける17-Ketosteroidの研究 17-Ketosteroidの臨床的研究 第 III 篇 : 尿 Author(s) 卜部, 敏入 Citation 泌尿器科紀要 (1958), 4(1): 3-31 Issue Date URL
Title 泌尿器科領域に於ける17-Ketosteroidの研究 17-Ketosteroidの臨床的研究 第 III 篇 : 尿 Author(s) 卜部, 敏入 Citation 泌尿器科紀要 (1958), 4(1): 3-31 Issue Date 1958-01 URL http://hdl.handle.net/2433/111559 Right Type Departmental Bulletin
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