Addiction Medicine Update University of Florida Scott Teitelbaum, M.D. Vice Chairman & Chief of Addiction Medicine, President FSAM

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1 Addiction Medicine Update University of Florida Scott Teitelbaum, M.D. Vice Chairman & Chief of Addiction Medicine, President FSAM 1

2 NIMH s Annual Report : Top 10 Research Advances of Grand Challenges in Global Mental Health. Mental, neurological, and substance use (MNS) disorders account for 13% of the global burden of disease, more than cancer and cardiovascular disease (15). It is becoming very clear that there is no health without mental health and that without efforts to identify and treat the substance abusers and mentally ill, more and more of the health dollars are spent on Band-Aids and revolving doors. European Union and global recognition of the economic costs of mental illness (17) and the importance of including mental health in global health care (18, 19) is clear, but often ignored and unfunded. (15) World Health Organization. The Global Burden of Disease: 2004 Update (WHO, 2008). (16) Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS et al. Grand challenges in global mental health. Nature Jul 6;475(7354): (17) Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Mowafi M, Pandya A, Prettner K, Rosenberg L, Seligman B, Stein A, Weinstein C. The Global Economic Burden of Non-communicable Diseases. Geneva, Switzerland: World Economic Forum, 2011 (18) Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, Ntulo C, Thornicroft G, Saxena S. Scale up of services for mental health in low-income and middle-income countries. Lancet Oct 29;378(9802): (19) Raviola G, Becker AE, Farmer P. A global scope for global health--including mental health. Lancet Nov 5;378(9803):

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6 UF College of Medicine

7 UF Division of Addiction Medicine Research Clinical Teaching

8 University of Florida is Leading The Nation Addiction-Related Brain Science Treatment Research Education Epidemiology & Toxicology Recovery Programs for Professionals Scholarly & Prevention Activities from Gainesville to Beijing

9 UF Distinguished Alumni Professor ( )

10 Addiction Medicine

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12 Meet The Experts: Division of Addiction Medicine Detoxification Inpatient Treatment Partial Hospitalization Impaired Professionals Treatment Outpatient Evaluation and Treatment Suboxone Maintenance

13 20 Addiction Researchers at UFCOM Led By Mark S. Gold, MD Mark H. Lewis, PhD John M. Petitto, MD Nicole M. Avena, PhD Sara Jo Nixon, PhD Lewis R. Baxter, Jr., MD Habibeh Khoshbouei, PharmD, PhD Lisa J. Merlo, PhD Karen M. von Deneen, DVM, PhD Yijun Liu, PhD Firas H. Kobeissy, PhD Adriaan W. Bruijnzeel, PhD Barry Setlow, PhD Bruce Goldberger, PhD Drake Morgan, PhD Todd E. Golde, MD C. Shawn Dotson, PhD Sylvain Dore, PhD Marcelo Febo, PhD Kevin Wang, PhD Updated 9/27/11

14 Food Addiction and Obesity: Evidence from Bench to Bedside Liu Y, von Deneen KM, Kobeissy FH, Gold MS. Journal of Psychoactive Drugs, 2010; 42(2): Associated with both substance related disorder and eating disorder Many shared neural and hormonal pathways Distinct differences fmris of obesity and drugs of abuse show same characteristics Acquired drive with respect to motivation and incentive

15 2012:Progress in Basic Addiction Science Drugs Change the Brain Over Time- Prevention is the Best and only 100% Effective Rx Early or Pediatric Exposure Makes Abuse and Dependence Most Likely- Cigarettes, Alcohol, Drugs Genes are not destiny but do matter how long from use until dependence; choice of drug or drugs; exposures as a child or in utero trump genes or may actually change them Drugs Switch the Brain and Occasional Use Becomes Addiction or Dependence Drugs Hijack the Brain New Understanding & New Therapies Possible

16 ADDICTION IS A DISEASE OF THE BRAIN As other diseases, it affects tissue function Decreased Brain Metabolism in Drug Abuse Patient High Control Cocaine Abuser Decreased Heart Metabolism in Heart Disease Patient Low Healthy Heart Diseased Heart Sources: From the laboratories of Drs. N. Volkow and H. Schelbert

17 Dopamine D2 images of Drug Addiction Cocaine Control Abuser Heroin Control Abuser Methamphetamine Control Abuser Alcohol Control Abuser Drug abusers have low brain dopamine activity (shown here using [ 11 C]raclopride PET studies) indicating an under stimulated reward system. National Institute on Drug Abuse. Addiction Science: From Molecules to Managed Care. Available at: 17

18 The Memory of Drugs Front of Brain Amygdala not lit up Amygdala activated Back of Brain Nature Video Cocaine Video

19 UF s 2012 Addiction Research Highlights Dynamic cause-effect relationships between risky decision making and drugs of abuse Second and third hand Opium exposure compromises children in Afghanistan Novel lead compounds (5-HT(2C) agonist/5-ht(2a) inverse agonist) for drug development for obesity, addiction and neuropsychiatric disorders Identification of novel drug targets for treatment of RRB in autism Proteomic changes following second-hand smoke exposure Methamphetamine damages brain cells like head trauma does Development of nanotechnology for determination of alcohol/drug concentrations (e.g., exhaled breath to measure blood ethanol concentrations) Overlaps that exist in brain mechanisms that promote ingestion of food and drug abuse New pharmacological treatment for food addiction Long-term internet addiction and brain structural alterations

20 METH Use Neuronal Damage Similar to Traumatic Brain Injuries Accumulated evidence indicates that acute administration of METH leads to neuronal damage in several brain regions that is similar to traumatic and ischemic brain injuries via activation of calpain and caspase proteolytic systems METH exposure, like TBI can cause both apoptotic and necrotic cell death METH addicts might benefit substantially from long-term rehabilitative approaches in conjunction with neuroprotective agents similar to those used in trauma patients. Gold MS, Kobeissy FH, Wang KKW, Merlo LJ, Bruijnzeel AW, Krasnova IN, Cadet JL. Methamphetamine- and trauma-induced brain injuries: Comparative cellular and molecular neurobiological substrates. Biological Psychiatry 2009 Jul 15;66(2):

21 International Collaborations/Global Health Fogarty grant to provide behavioral health training in India and increase research opportunities between UF and Indian partners Neuroimaging collaborations with Chinese investigators and China s NSF Canada Drugs and Children- Calgary Second hand drug exposure: Afghanistan and Brazil

22 Target is the Brain Tobacco Smoking No one smokes for foul smelling clothes or a cough or bad breath or cancer Smoking is injecting a drug without a needle rapid delivery of smoke containing nicotine and other drugs to brain targets Filter is an oxymoron accelerator is more like it SHS is first hand smoke against your will Smoking mother = huge increased risk of a smoking adolescent Teen smoker= Lifelong, chronic relapsing, smoker MSG 22

23 Smoke > IV > IM sniff > oral

24 Withdrawal Syndromes Do Not Define Drugs of Abuse or Addiction MSG 24

25 Addiction Is Not Withdrawal Most pain patients on chronic treatment have withdrawal if they stop their medications, but few are addicts Addiction is pathological attachment Desire and motivation to take a drug Compulsive Self Administration after initial use & Loss of Control Continued Compulsive Use Despite Extreme Consequences Continuous Thinking or Seeking of Drugs Even When They Are Unavailable Librium treats alcohol withdrawal but not the alcoholic. MSG 25

26 VTA Amphetamines Opiates THC PCP Ketamine Nicotine Nucleus accumbens Alcohol benzodiazepines barbiturates Dopamine Pathways

27 The processes that initiate and maintain alcoholism are regulated by interactions among nerve cells in the brain. Biological Influences susceptibility to drug usage Socio-cultural Psychological Environmental

28 NIH/NIDA 28

29 Hypofrontality in Cocaine Dependent Patients Reduced Metabolic activity at baseline in cocaine dependent subjects 29

30 Drugs Attack the Prefrontal Cortex & Dependence Consequences are related to dysfunctions in the Prefrontal Cortex Unfortunately the Prefrontal Cortex is Critical for : Decision-making Weighing of risks vs. rewards Assigning emotional valence to stimuli Suppressing limbic impulses Goal-directed behaviors 30

31 Motivational Toxicity Why work so hard for rewards if reward can be produced by smoking, drinking or drugs? Intense motivation is critical in the disease of addiction Hierarchy of work-reward disrupted Pathological attachment or Fatal Attraction Brain is unprepared by evaluation for reward n demand or cocaine Drug effects persist forever: in coded bad learning and with relapse, re-addiction can occur very quickly. Our Group has also shown some drugs cause brain cell damage and loss too! 31

32 Drug Use Trends In 1962, only 2% of the U.S. population over the age of 12 years had tried an illegal drug By the mid 1980s, nearly 50% of the population had experimented with an illegal drug National Survey Drug Use and Health (NSDUH) Available at https://nsduhweb.rti.org 32

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35 Past Year Marijuana Use th 10th 12th UM NIDA Monitoring the Future Study Updated 1/30/12

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37 Gateway Drug

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39 Marijuana Use Linked with Increased Risk of Motor Vehicle Crashes Greater the amount of marijuana in a person s urine, the greater the risk of a car crash 28% of drivers who died in an accident tested positive for non-alcohol drugs (most commonly, marijuana) Marijuana use by drivers is associated with a significantly increased risk of being in a motor vehicle crash. Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana Use and Motor Vehicle Crashes. Epidemiologic Reviews. Advance Access published October 4, 2011.

40 Drug and alcohol involvement in four types of fatal crashes Drivers who die in crashes test positive for drugs 25% of the time (44,239 drivers; 24 states) Fatal crash subtypes: failure to obey/yield; inattention; speeding; seat belt misuse Alcohol positives: 42% Drug positives: 24.9% Most prevalent drug classes: cannabinoids 22.7%; stimulants 22.5%; multidrug 14.9% Romano E and Voas RB. Drug and alcohol involvement in four types of fatal crashes. J Stud. Alcohol Drugs, 2011; 72:

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42 Marijuana Perceived Risk vs. Use

43 PERCENT Marijuana Primary Substance of Abuse at Admission to U.S. State Licensed or Certified Substance Abuse Treatment Facilities, Ages 12 and Older, YEAR

44 Anhedonia and Abstinence Drugs produce sense of well being and euphoria Drugs of abuse change the brains set point for reward and pleasure Drug withdrawal produces depression and anhedonia MSG 45

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46 Dopamine Pathways Serotonin Pathways frontal cortex Functions reward (motivation) pleasure, euphoria motor function (fine tuning) compulsion perseveration striatum nucleus accumbens hippocampus substantia nigra/vta raphe Functions mood memory processing sleep cognition MSG 47 47

47 Prescription Misuse, Abuse, & Addiction More Emergency Room admissions More overdose deaths More problems with Poly Pharmacy More older Americans addicted to pain medicines many are still in pain More need for addiction treatment of teens to elder adults

48 Generation Rx 18% of teens have abused Vicodin 20% tried Ritalin or Adderall without Rx 9% abused OTC cough syrup to get high More teens had abused a prescription painkiller in 2004 than Ecstasy, cocaine, crack or LSD April 21, Partnership for a Drug Free America. 17th annual study of teen drug abuse.

49 Prescription Drugs 1 in 4 high school seniors report using psychoactive medication without medical supervision Sedatives Narcotics Barbiturates Amphetamines

50 Might Not Meet Today s FDA Standards

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53 Many Adolescents Report Prescription Drug Abuse Data from 2005 National Survey on Drug Use and Health found 8.2% of teenagers (12-17 years) report misusing at least 1 prescription drug in the prior year. Opioids were most misused. N=18,678. Schepis TS, Krishnan-Sarin S. J Am Acad Child Adolesc Psychiatry. 2008;47(7):

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55 . Bailey JA, Hurley RW, Gold MS. Crossroads of Pain and Addiction. Pain Medicine. 2010; Wiley Periodicals, Inc. Crossroads of Pain and Addiction Patients with coexisting addictive disorders and chronic pain are common and represent some of the most difficult patients in the field of medicine. Few pain training programs offer significant experiential and didactic training in drug abuse and addiction Addiction medicine programs offer little training in pain management Patients with coexisting pain/addiction have a decreased pain tolerance, increased anxiety, depression and sleep disturbances Collaboration of these two fields can lead to successful management of patients with coexisting chronic pain and addictive disorders

56 High School Survey Annual Oxycontin Use th 10th 12th UM NIDA Monitoring the Future Study

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58 M.D.s Rarely Make A Diagnosis University of Pennsylvania study : Only 3% of patients in treatment for addiction came because of a M.D. referral MSG 59

59 Huge Public Health Problem MDs Are Out of the Loop and getting worse Penn Addiction Referral Sources Source of Addiction Referrals Drug Courts, Police, Criminal Justice 38% 59% Employers/EAP 10% 6% Welfare/CPS 8% 16% Hosp/Phys 4% 3% MSG 60

60 Alcohol Screening by PCPs < 1/3 of U Penn alcoholic inpatients were seen recently by their MD or health provider. Few, if any, were screened using a CAGE or other rapid assessment screen for alcohol or drug problem Even if an alcoholic in need of treatment was found < 1/2 were given any intervention or referral Edlund MJ, et al. Med Care 2004;42:

61 Top Physician Reasons for Not Screening 426 PCPs at the Society of General Internal Medicine 1. Don t know what to do 69% 2. No effective treatment 55% 3. Not really a medical problem 26% 4. No time 19% A. Thomas McLellan, Ph.D. ONDCP and University of Pennsylvania. Personal communication, 2008.

62 UF COM Education Undergraduate Medical Students Pas & Nurses Interns & Residents Fellowship

63 Mandatory Addiction Medicine at UF Clerkship, Not Classroom Imagine learning how to deliver a baby by listening to a lecture or reading Competencies only possible by seeing, learning, doing, and improving intervention, interviewing, diagnostic skills, detox, and treatment skills of the MD The data on MD performance is a reflection of the lack of actual experience they receive in addiction medicine

64 ASAM-ABAM Recognizes UF In the past, the specialty was very much targeted toward psychiatrists, said Nora D. Volkow, the neuroscientist in charge of the National Institute on Drug Abuse. It s a gap in our training program. She called the lack of substance-abuse education among general practitioners a very serious problem. Institutions offering the one-year residency are St. Luke s-roosevelt Hospital in New York, the University of Maryland Medical System, the University at Buffalo School of Medicine, the University of Cincinnati College of Medicine, the University of Minnesota Medical School, the University of Florida College of Medicine, the John A. Burns School of Medicine at the University of Hawaii, the University of Wisconsin School of Medicine and Public Health, Marworth and Boston University Medical Center. The new accreditation comes courtesy of the American Board of Addiction Medicine, or ABAM, which was founded in 2007 to help promote the medical treatment of addiction. NY Times July 10, 2011

65 Addiction Medicine Leadership Group Scott Teitelbaum, M.D. - Double Boarded Pediatrician and Addiction Medicine Vice Chairman, Chief of Addiction Medicine s 12 full time MDs and FRC Medical Director. President of Florida ASAM, Committees at ASAM, one of only 10 ABAM GME Fellowships & one of 3 with NIAAA funding. National Expert, Evaluator PRN, IPN, 37 State Boards of Medicine & NY Yankees. Frequent national media expert and called as an expert to the White House.Built FRC from State to National prominence. Martha Brown, M.D. -Double Boarded Psychiatrist and Addiction Psychiatrist Formerly USF Dean, LSU Associate Professor & Head of Louisiana s Impaired MD programs. PRN (Florida) Associate Medical Director (50% effort) working with all Florida Medical & Health Specialty Boards. Extensive work in La., Fl. and Southeast as an Impaired Nurse and MD evaluator and Nationally as an expert for Professional Sports, especially NFL and NBA. UF s Pain Fellowship GME Program Co-Director and Pain CME ; Professionalism and Mis-Prescribing Director. Regional Expert. Kevin Wandler, M.D. - Double Boarded Psychiatrist & Addiction Medicine Pioneering Anorexia Nervosa, Eating Disorders and Dual Disorders Evaluation & Treatment Expert Psychiatrist and then CMO for Remuda Ranch safely treating >10,000 patients National Expert, BOD for Eating Disorders Societies Academy for Eating Disorders, International Association of Eating Disorders Professionals, & Christian Psychiatry Mark S. Gold, M.D. - Distinguished Professor, Eminent Scholar, and Chairman of 80 Faculty UFCOM Department. Inventor, Researcher & Author of nearly 1,000 scientific papers, books, and commentary. Inventor with 15 patents including Clonidine, Dopamine Hypothesis, Obesity Rx & Medication Adherence. Distinguished Alumni Awards from Wash U, Yale, and UFL. UpToDate Editor, International Expert from WHO to China-Japan to NAS in 80s on Tobacco and today on Obesity. Contracted Long-Term Consultant Positions to Major Wall Street firms (Lehman, Goldman, Carlyle, Cressy) Regularly Quoted expert on new technologies in WSJ, Bloomberg, CNN, and Others this year alone. Founder of FRC and first Addiction Medicine hire at UF

66 Recovery Evidence does not support fast brain recovery Evidence from NIDA s Director Nora Volkow, M.D. and others failed to show brain recovery after many months of successful treatment While brain recovery can and does happen with abstinence, treatment, exercise, and diet it takes years and not days

67 Normal Cocaine Abuser (10 Days) Cocaine Abuser (100 Days)

68 The nucleus accumbens lighting up The Target is Always The Brain, however

69 While science has taught us that addiction is a hijacking of the brain, recovery must involve healing of the heart and the soul.

70 Percent of Patients Who Relapse 100% 80% 60% 40% 20% 0% Drug Abuse Is a Treatable Disease Comparison of Relapse Rates Between Drug Addiction and Other Chronic Illnesses 40%-60% Drug Addiction 30%-50% Type I Diabetes 50%-70% 50%-70% Hypertension Asthma Addiction. NIH News National Institutes of Health. Available at: Accessed June 16, 2008.

71 Similarities to Other Medical Disorders Substance addiction comparable to asthma, hypertension and diabetes. Risk of relapse highest during first 3-6 months. Length of time in treatment is key Patients respond best to a combination of self help and behavioral interventions. Treatment of severe cases & dual disorders requires experts but, improves outcomes

72 Percent of Patients Who Relapse 100% 80% 60% 40% 20% 0% Drug Abuse Is a Treatable Disease Comparison of Relapse Rates Between Drug Addiction and Other Chronic Illnesses 40%-60% Drug Addiction 30%-50% Type I Diabetes 50%-70% 50%-70% Hypertension Asthma Addiction. NIH News National Institutes of Health. Available at: Accessed June 16, 2008.

73 What is recovery? A working definition from the Betty Ford Institute The Betty Ford Institute Consensus Panel There is an unknown but very large number of individuals who have experienced and successfully resolved dependence on alcohol or other drugs. These individuals refer to their new sober and productive lifestyle as recovery. Although widely used, the lack of a standard definition for this term has hindered public understanding and research on the topic that might foster more and better recovery-oriented interventions. To this end, a group of interested researchers, treatment providers, recovery advocates, and policymakers was convened by the Betty Ford Institute to develop an initial definition of recovery as a starting point for better communication, research, and public understanding. Recovery is defined in this article as a voluntarily maintained lifestyle composed characterized by sobriety, personal health, and citizenship. This article presents the operational definitions, rationales, and research implications for each of the three elements of this definition. Journal of Substance Abuse Treatment 2007; 33:

74 What is recovery? A working definition from the Betty Ford Institute The Betty Ford Institute Consensus Pane (Dr Gold was a member of this panel ) Journal of Substance Abuse Treatment, 2007; 33: Recovery = a voluntarily maintained lifestyle characterized by: Sobriety Early (1-11 months) Sustained (1-5 years) Stable (> 5 years) Personal health Physical Mental Social Spiritual Citizenship Giving-back Quality of life

75 Setting the standard for recovery: Physicians Health Programs DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Journal of Substance Abuse Treatment, 2009; 36: physicians admitted to 16 state PHPs studied for 5 years Elements of success: Abstinence-based programs Frequent random tests for 5 years Close linkages to 12-step programs Use of residential/outpatient programs rated excellent

76 MD Addicts: 5-Year Outcomes Status of Medical Practice Medical Status (Last Known) Working in Medicine Licensed/ Not Practicing Not Licensed/ Suspended License Completers, % (n = 448) Continuers, % (n = 199) Noncompleters, % (n = 257) Total Sample, % (n = 904) Retired/ Left Practice Died Unknown DuPont RL, et al. Setting the Standard for Recovery: Physicians Health Programs. The Betty Ford Institute Meeting, Rancho Mirage, CA; October 3-4, 2007.

77 Essential Ingredients of the PHP Model Contingency management with positive consequences for abstinence and active intervention for any use of alcohol or other drugs of abuse Frequent random drug testing Abstinence standard drugs and alcohol Link to 12-step programs Active management of relapse Long-term continuing care and monitoring Focus on life-long recovery

78 Challenges Increasing Rx misuse Younger age of onset of use More MJ smoking youth Poly Drug, alcohol users teens Dual Disorders MDs role in Rx misuse Aging Floridians and Addictions Health Providers-MDs role in failure to Dx ED-ERs role in failure to DX and intervene

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