Premise. Addiction. 12 Steps as Medicine. Addiction. A primary, chronic disease of brain reward, mo<va<on, memory and related circuitry Addic%on

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1 Premise 12 Steps as Medicine! Kenneth W. Thompson 12 Step interventions are a disease modifying intervention that often improves all aspects of addiction - bio, psycho, social and spiritual 12 Step interventions can be viewed as a medicine A primary, chronic disease of brain reward, mo<va<on, memory and related circuitry Addic%on is a primary, chronic disease of brain reward, mo<va<on, memory and related circuitry. Dysfunc<on in these circuits leads to characteris<c biological, psychological, social and spiritual manifesta<ons. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. (ASAM defini<on) Dysfunc<on in these circuits leads to characteris<c biological, psychological, social and spiritual manifesta<ons Addiction This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction

2 Wellness/Recovery ASAM/SAMHSA Put disease into remission To identify & address barriers to long term recovery To promote the best state of wellness at any given time To promote the best possible chance for long term recovery Process of change through which the individual improves his health and wellness, live a self directed life and strive to reach their full potential. Health Home Purpose Community No Mention of Abstinence! Wellness Wellness - and Abstinence from all drugs that pathologically stimulate the reward pathways is to be considered an optimal component of wellness (recovery). Depending on biopsychosocial and/or economics, drugs such as buprenorphine might be necessary for a period of time and sometimes indefinitely to support the best state of wellness. Abstinence from the pursuit of any behaviors that pathologically affect the reward area is to be considered an optimal component of wellness (recovery). Obstacles to Wellness Medications Effective Medical Social Psychological Developmental Addiction Interactive Doctors Spiritual Treatment 1. Withdrawal management 2. Post acute withdrawal 3. Cravings 4. Blockade/Deterrents

3 Medication Not Effective 12 Steps PFC Naltrexone Suboxone Response to environmental cues Memories associated with drug usage Rewired brain and altered chemistry Change in gene expression/epigenetic Emotional damage, shame & guilt Unmanageability Family damage/social damage Spiritual changes Addiction Package Insert Indications Ingredients Effectiveness Mechanism of action Dosing Side Effects Safety Drug Interactions Monitoring INDICATIONS Indications For the treatment of Addiction Indications for Meds cravings hypodopaminergic state? - latent withdrawal acute withdrawal blockade deterrent

4 Indications Restless, irritable, discontent hopelessness withdrawal Cravings Loneliness Withdrawal Relationship problems Unhappiness Financial worries Baffling life problems Regrets about the past Lack of serenity Self pity Loss of interest Selfishness INGREDIENTS Fear of people Difficulty handling situations Lack of freedom troubling secrets personality problems Spiritual distress - anger, depression, worry Ingredients Interventions Twelve Step Interventions Love Twelve step facilitation as studied in Project Match and performed in our treatment programs is only a part of Twelve Step Interventions meetings fellowship service steps sponsor- ship Traditions Inert Ingredients Holds AA together Anonymity No opinion Self supporting Autonomous Principles before personalities Only requirement EFFICACY

5 Limitations of Studies on 12 Step Difficult to control variables Anonymous program Most studies on alcohol abs<nence Most have been done on AA Most studies on adults Most looked at ajendance, engagement and alcohol use - not recovery Measurement of steps not done Paucity of informa<on on long term involvement in AA & NA Not Effective Reviewed studies to determine effectiveness of AA and TSF 8 trials involving 3417 patients Conclusion: No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches Cochrane Review Generalizations Multiple studies show that attendance of AA and NA associated with better alcohol and drug related outcomes More frequent attendance, more likely sober Deeper the involvement, improved outcomes People who sponsor stay sober Persons completing 4th step more likely stay sober Effectiveness of AA Six Criterion 1. Plausibility 2. Magnitude of effect 3. Dose response effect 4. Consistent effect 5. Temporally accurate effects 6. Specific effects Kaskutas 2011 Project Match At 3 years - abstinence TSF 36% CBT 24% MET 27% Many in CBT and MET also went to AA 16 year - Outcome 16 year Followup individuals who participated in AA for 27 weeks or more had better 16-year outcomes Involvement in AA predictor of success Contribution of AA independent of treatment Twelve step facilitation as studied in Project Match and performed in our treatment programs is only a part of Twelve Step Interventions Moos, et al; J Clin Psychol 62: , 2006

6 Efficacy AA effectiveness holds true even if consider for bias of those who might attend AA in first place. Kelly Efficacy Persons in treatment where AA was an integral part of tx compared to not an integral part of treatment AA lower health care costs AA improved outcomes AA less re-utilization of treatment Humphreys, et al, 2004 Causal Relationship Although randomized controlled trials are the surest means of establishing causal relations between interventions and outcomes, such trials are rare in AA research for practical reasons. The current study successfully exploited the multiple data waves in Project MATCH to examine evidence of causality between AA participation and drinking outcomes. The study obtained unique statistical results supporting the effectiveness of AA primarily in the context of primary outpatient treatment for alcoholism. Magura St 2013 Re-exam Project Match AA and Physicians 100 impaired physicians completing tx An average of 33.4 months after admission still abstinent Rated Alcoholics Anonymous (AA) as more important to their recovery than professionally directed modalities. Feelings of affiliativeness to AA was a strong predictor of the respondents' recovery. Galanter, M., et al., Combined Alcoholics Anonymous and professional care for addicted physicians. Am J Psychiatry, (1): p Outcomes of Physicians Amazing outcomes 88-92% abstinent Almost no physicians on OMT, few on any psychotropics Factors Implicated in the success rates Often are treated longer Contingency management Frequent random drug testing Tight linkage with 12 steps and abstinence standard espoused by these programs Active management of relapses by intensified treatment and monitoring Continuing care approach Focus on lifelong recovery Dupont, et al, 2011

7 Long Term AA AA 47% attendees sober at least 5 years (2007 General Service Office Survery) 24% maintained continued Twelve Step involvement or those who entered AA (NESARC by NIAAA) 74% had received specialty treatment; 36% abstinent over 5 years (Grant NIAA, 2003) Among the most reliable and robust findings from clinical studies of alcohol and drug addicted patients is that continued, active participation in Alcoholics Anonymous or other social-support form of recovery maintenance is an excellent predictor of sustained sobriety and good social function. (McLellan 2013) MECHANISM OF ACTION HOW IT WORKS No one knows why it works when it does work (Kaskutas) Mechanisms of AA Repeated recovery thoughts & behaviors act through brain plas<city to state of wellness Increased self- efficacy, coping and mo<va<on for abs<nence (Kelly 2009, Morgenstern 2002) Facilita<ng changes in social networks (Bond et al 2003, and others) Reducing depression (Kelly 2010) Mechanisms of Action Increased self-efficacy, coping and motivation for abstinence (Kelly 2009, Morgenstern 2002) Facilitating changes in social networks (Bond et all 2003, and others) Reducing depression (Kelly 2010) Humor (Kaskutas) Love - unconditional acceptance

8 Other Mechanisms Mechanism of Action Meetings story telling brain changes likely involved benefit of helping people learn for themselves (heuristic) Activate PFC - Parables, metaphors, anecdotes, sage sayings, & mirroring behavior Galanter 2013 Mechanism of Action Meetings Socialization hard-wired in our brains Activation of limbic reward centers seen in fmris Increase Oxytocin, decreased cortisol Teresi, Haroutunian Hijacking the Brain Mechanism of Meetings Sober social support Reduces shame from common bond Provides Hope success of others Safe place to tell the truth Wisdom from others Process anger, resentments, negative emotions Reminder witness relapse Group provides higher consciousness Directions to a spiritual awakening Steps Having had a spiritual awakening Higher Power An observation noted in Big Book Pain Suffering Fear Guilt Sadness Secrets Shame We admitted we were powerless chapter 3 of big book - that thought that comes for which only a Higher Power could stop it Not even Suboxone!!!

9 Power of the Fourth Step 12 Having had a spiritual awakening as the result of these steps, we tried to carry this message to others, especially addicts, and to practice these principles in all of our affairs (Service) diagnostic heuristic explores secrets evaluates anger, fear, resentments treats symptoms that cause uneasiness identifies character defects which require energy (drain spirit) All uneasiness is not the result of hypodomaninergia Transformation Less selfish Concern for others A connection Purpose Community Can t keep it if you don t give it away. Spiritual Experience Functions localized in specific brain sites may also be related to states associated with phenomena typically ascribed to spiritual experiences, as has been noted in relation to interictal experiences of hyperreligiosity associated with temporal lobe epilepsy (Ogata & Miyakawa, 1998). During electric stimulation undertaken to find epileptogenic foci, it was found that out-of-body experienc- es (such as seeing one s body in extrapersonal space) were elicited by stimulation of sites at the temporo-parietal junction (Blanke et al., 2002). More complex spiritually related experiences may also be localized, since dreamimagery, like that experienced in spiritually grounded states, can be understood to emerge from certain loci. Hobson, Pace-Schott, and Stickgold (2000) described a model for dream experiences wherein hallucinosis is activated in pons, and affect in limbic sites, while the prefrontal areas responsible for self-aware- ness and insight are suppressed. Stimulation of right parietal lobe may result in description of having had a spiritual experience My Stroke of Insight Jill Bolte Taylor, PhD Significant interactions have also been found between encoding for both the transcription factor AP2β and the serotonin transporter, and psychometric measures of the character trait of spiritual acceptance (Nilsson et al., 2007). Spiritual/Religious Ac<vi<es AA leads to bejer alcohol use outcomes in part by enhancing individuals spiritual prac<ces Assessed: Belief in God (no à I believe in God and prac<ce religion) In past 90 days have you prayed, thought about God, Meditated, ajended worship services, read or studied Holy wri<ngs, had direct experience with God? AA ajendance associated with increased S/R AA ajendance associated with lower drinking Kelly Spiritual Awakening Young People AA those who reported a spiritual awakening by their 3rd year were 3 times as likely to be abstinent at time of followup (Kaskutas, The role of religion, spirituality and alcoholics anonymous in sustained sobriety. Alcohol Treat Quart 2003; 21:1-15) Prior religiosity or affiliation was not a factor Majority of physicians in long term AA experienced this and were more likely sober (Galanter 2013) 266 regular attendees in AA averaged 6 years involvement 36% no formal treatment experience most had sponsors and sponsored 92% had spiritual awakenings mean duration abstinence 44 months Galanter 2013

10 Narcotics Anonymous 527 in NA (US) used drugs average 6.1 years more spiritual than religious spiritual experience > less drug use, less cravings Marc Galanter, MD, Helen Dermatis, PhD, Stephen Post, PhD, and Cristal Sampson, BA March 2013 NA First Look at NA attendees 396 NA members questionnaire (80% participated), regularly attended NA the past year majority had received both inpatient and outpatient tx for substance abuse 26.5% psychiatrically hospitalized cocaine & heroine most prevalent (followed by synthetic opioids, methamphetamine) most started in their 20 s 36% referred by professionals most had sponsors, 50% had been sponsors majority endorsed powerlessness and need to turn life over to God 84% felt cared for by NA members 84% described a spiritual experience ** participants were in long term remission, Twelve Step program membership may serve as a useful and cost-free means of bolstering professional care Galanter 2013 Sponsor Sponsoring & Service Work Acts as pre-frontal cortex Accountability Guides through steps Provides purpose, meaning, usefulness People who sponsor stay sober (Tonigan) DOSING

11 Dosing of Meetings Loading dose: 90 meetings in 90 days Maintenance dose: >= 1 per week Meeting Flavors Open and closed Types Men's, women s Young, older Gay/lesbian Beginner Style Speaker (Story) Discussion Step groups, Big Book study Meeting Strengths Cohesiveness of a meeting makes a difference (Kelly) Safety Safety No reports of overdose Does not dysregulate the limbic system Has no street value Safe to use in the co-morbid psychiatric disorders

12 Side Effects Reminder of trauma 13 th Steppers - victimization Hold sponsor in too high a regard Increase anxiety Bar of total abstinence - failure SIDE EFFECTS Drug Interactions DRUG INTERACTIONS Compatible with other modalities of treatment such as CBT, MET, psychiatric May be used (should be used) with naltrexone, buprenorphine (Suboxone) and methadone Warning! The use of mood altering drugs such as buprenorphine (Suboxone) may interfere with the absorption of 12 step interventions. COST

13 COMPLIANCE Compliance MOST PEOPLE DROP OUT OF AA! Research studies done to date have generally found that only about 25-35% of those who attend one meeting of AA go on to active participation (e.g. attend 90 meetings, acquire a sponsor, etc.). (McLellan) Barriers Not contraindications Improve Palatability! Preformed opinions Social anxiety Perceived religiousness or cult-like Agnostic, atheist Prior failure Lack peer group Non acceptance of maintenance drugs

14 Improve Absorption Physicians 144 physicians in recovery in long term AA alcohol 46%; only other drugs 6%; both 48% those in PHP more likely to do 90 in 90 more likely to be spiritual rather than religious 66% received treatment average sobriety months 69% enrolled in PHP 74% did 90 meetings in 90 days at some point 77% referred to AA by professional Most frequent meeting attenders Galanter; Physicians in Long Term Recovery July American Journal on Addictions! Resistance Compliance Initial resistance of physicians in New York study, subsequently attended (galanter, Am J Addict 2007) Attendance of meetings can be influenced by type of treatment and counselor (Project Match and VA study) MAAEZ Coercion has been effective with drug courts, physician, pilot & lawyer programs Warning Label or Physician Advice Addiction is a chronic medical disease. 12 Steps is indicated for all aspects of the disease Failure to take all your medication may result in relapse. Take full dose of meetings, service work and step work daily Remember there are 12 steps. THE END