THE DISEASE OF ADDICTION: A Primer. The 10 th Annual Kinship Conference for Grandparents and Relatives South Burlington, Vermont 9 September 2014

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1 THE DISEASE OF ADDICTION: A Primer The 10 th Annual Kinship Conference for Grandparents and Relatives South Burlington, Vermont 9 September 2014

2 3 BASIC QUESTIONS AT THE KITCHEN TABLE 1. Why don t they just stop? 2. Does treatment really work? 3. How does treatment work?

3 1. WHY DON T THEY JUST STOP? Those people are weak-willed, lazy, irresponsible and sociopathic. Those people are dependent, moral degenerates, liars and floozies. Those people could stop if they put their mind to it.

4 THE FACTS Equal opportunity destroyer : not correlated with gender, education, professional status, or sociopathy BIO-BEHAVIORAL change from voluntary control to compulsive & uncontrollable

5 ADDICTION: SIMPLY DEFINED Continued use despite consequences.

6 ADDICTION: (MIS)UNDERSTOOD Fundamental brain changes associated with assault of toxic substances: Neuro-circuitry, neurotransmitters, anatomy Changes in brain function: Judgment, memory, impulse control, will ( brain quadriplegia ) Data: fmri, PET scans, animal studies Current diagnostic methods are primitive Range in loss of biobehavioral control

7 BRAIN MOLECULAR TARGETS OF DRUGS AND ALCOHOL Classes of Drugs Primary Target Alcohol Targets Caffeine Nicotine Depressants Barbiturates Benzodiazepines Marijuana/THC Opioids Stimulants Cocaine Amphetamines Hallucinogens LSD MDMA PCP Ketamine Inhalants Adenosine Receptors Nicotinic Ach receptor GABA receptors GABA receptors Cannabinoid receptors Opioid receptors Dopamine transporters Dopamine/NE release Serotonin receptors Serotonin receptors NMDA receptors NMDA receptors?? NMDA receptors (blocked) Kainate receptors (blocked) GABA receptors (stimulated) Glycine receptors (stimulated) Nicotinic Ach receptors (stimulated) Serotonin receptors (stimulated) Calcium channels (blocked) Potassium channels (blocked) Protein Kinase C Protein Kinase A DARPP-32 Phosphatases Neurosteriods

8 SUBSTANCE USE DISORDER Diagnosis associated with: Alcohol Cannabis Phencyclidine Other hallucinogens Inhalants Opioids Sedatives, hypnotics, or anxiolytics Stimulants Tobacco Other (or unknown)

9 DIAGNOSTIC CRITERIA Problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

10 IMPAIRED CONTROL (Criterion 1-4) 1. Substance is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 3. A great deal of time is spent in activities necessary to obtain substance, use substance, or recover from its effects. 4. Craving, or a strong desire or urge to use substance.

11 SOCIAL IMPAIRMENT (Criterion 5-7) 5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home. 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. 7. Important social, occupational, or recreational activities are given up or reduced because of substance use.

12 RISKY USE (Criterion 8-9) 8. Recurrent substance use in situations in which it is physically hazardous. 9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance.

13 PHARMACOLOGICAL CRITERIA (Criterion 10-11) 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of substance to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of substance. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for substance b. Substance is taken to relieve or avoid withdrawal symptoms.

14 SUBSTANCE USE DISORDER 11 Criteria Severity level: 0-1 = No Diagnosis 2-3 = Mild (~ Abuse) 4-5 = Moderate (~ Dependence) 6+ = Severe (~ Addiction)

15 ADDICTION SYMPTOMS: TRAJECTORIES OF ONSET BY SUBSTANCE

16 2. DOES TREATMENT REALLY WORK? No, look at all the failures and recidivism. No, it s a sham, they can stop on their own if they really want to. Maybe, but only if they really want to.

17 ADDICTION TREATMENT: COMPARISON WITH OTHER CHRONIC DISEASES Disease Inherited Outcome Relapse HBP % 50-70% Diabetes.80 60% 30-50% Asthma % 50-70% Addiction % 30 50% (McLellan et al, JAMA, 2000)

18 VARIABILITY IN TREATMENT OUTCOMES: CHRONIC DISEASES Stage of the disease: Early to Advanced Socioeconomic status (insurance benefits) Family and social supports Comorbid psychiatric conditions Motivational stage of patient Quality of treatment: Index episode and over time---chronic disease management

19 ADDICTION TREATMENT: (MIS)UNDERSTOOD Most people will not achieve maximum treatment benefits from a single treatment No single treatment type is adequate The most effective treatments combine evidencebased approaches and are delivered over time What happens outside of treatment is more important than what happens inside The process of treatment & recovery can progress from life saving to life changing

20 THE ACUTE CARE MODEL PATIENT WITH SYMPTOMS TREATMENT NTOMS Sample of 250 Programs PATIENT WITHOUT SYMPTOMS

21 ACUTE CARE MODEL: ASSUMPTIONS 1) Some fixed amount or duration of treatment will resolve the problem: Outcomes determined after discharge 2) Clinical efforts put toward matching treatment and getting patients to complete treatment: Single shot approach 3) Evaluation of effectiveness following completion: Poor outcome means ineffective treatment

22 CHRONIC DISEASE MANAGEMENT: ASSUMPTIONS 1) There are agreed upon clinical targets: Abstinence, less severe symptoms 2) Some combinations of treatments will achieve the clinical targets: Not just one single fixed treatment approach 3) There will be no discharge just reduced intensity of care over time: Recovery check-ups and monitoring

23 If addiction is a chronic disease then: We are neither treating nor evaluating the effectiveness of its treatments correctly.

24 OUTCOME STUDIES WITH HYPERTENSION Pre During During During Post

25 OUTCOME STUDIES WITH ADDICTION Pre During During During Post

26 LESSONS FROM CHRONIC DISEASE MANAGEMENT & EVALUATION Most patients do not respond to their first treatment (or medication). Treatment trials and combinations are most common and may maximize benefits. Ongoing monitoring is an accepted part of routine health care. Research (and clinical) evaluations of continuing care should occur during treatments, & over time.

27 MECHANISMS OF DENIAL 1. Biological: Memory, judgment, insight 2. Psychological: fear 3. Interpersonal: shame/guilt 4. Contextual: motives to disclose 5. Informational: knowledge of connections between use & consequences

28 3. HOW DOES TREATMENT WORK? It works because you make them change or else! You read them the riot act and break through the denial. They must go to detox then residential then aftercare then AA.

29 THE FACTS Understanding how treatment works is the most important area of current research. Several things have been established: 1) Assessment & Engagement Strategies 2) Problem - Service Matching 3) Duration of Treatment Matters

30 AMERICAN SOCIETY OF ADDICTION MEDICINE PATIENT PLACEMENT CRITERIA (The ASAM Criteria) No one size fits all. 1. Acute intoxication, withdrawal potential 2. Biomedical factors 3. Emotional/behavioral/cognitive factors 4. Readiness to change/treatment acceptance 5. Continued use and relapse potential 6. Recovery environment

31 VOLUNTARY VERSUS MANDATED TREATMENT Equivalent outcomes: Sustained over time Variety of contexts: Impaired physicians, transportation industry employees, addicted pregnant women, professional athletes Combination is better than one or the other alone: Treatment w/sanction > Treatment alone > Sanction alone

32 CORRELATES OF LONG TERM RECOVERY (n = 660) Vaillant (1995) Duration of abstinence: 5+ years ~ remission Alternative positive activities Peer support group involvement New primary (romantic) relationship Spiritual connection

33 15% 14% 13% 12% 11% 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Users/ Early Abstainers 2.87 times more likely to die in the next year The Risk of Death goes down with years of sustained abstinence It takes 4 or more years of abstinence for risk to get down to community levels 11.9% 7.1% 4.5% Household (OR=1.00) 3.8% Less than 1 (OR=2.87) Source: Scott, Dennis, Simeone & Funk (2011) 1-3 Years (OR=1.61) 4-8 Years (OR=0.84) 33

34 RECOVERY: A DEFINITION Betty Ford Institute Consensus Panel (2007) Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety*, personal health and citizenship**. *Sobriety: Early: < 1yr; Sustained: 1-5 yrs; Stable: 5+ yrs **Citizenship (Wikipedia): implies working towards the betterment of one s community through participation, volunteer work, and efforts to improve life for all citizens.

35 3 BASIC QUESTIONS AT THE KITCHEN TABLE 1. WHY DON T THEY JUST STOP? 2. DOES TREATMENT REALLY WORK? 3. HOW DOES TREATMENT WORK?

36 Mark McGovern Professor Department of Psychiatry & Department of Community and Family Medicine Geisel School of Medicine at Dartmouth 85 Mechanic Street, Suite B4-1 Lebanon, NH

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