cheif presentation - jerrold frank rosenbaum
TRANSCRIPT
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Agenda
I. Introduction & Overview
II. The Disease of Addiction
III. Population and Risk Factors
IV. Treatment
V. Center for Addiction Medicine Initiatives
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Substance Misuse: The Nation‟s Number One Public Health Problem
There are more deaths, illnesses, and disabilities from substance use than from any other preventable health condition Of the more than 2 million deaths each year in the US, 1 in 4 is
attributable to alcohol, tobacco, and illicit drug use
Alcohol alone causes about 20–30% of esophageal cancer, liver cancer, cirrhosis of the liver, homicide, epileptic seizures, and motor vehicle accidents worldwide (WHO, 2002).
Over 22.6 million Americans have problem with alcohol or other drugs More than half of all families in the US has or has had a family member
suffering from alcohol dependence (NIAAA, 2005)
Alcohol use is involved in 25-50% of suicides
37% of those with alcohol dependence and 53% of those with dependence on an illicit drug have another psychiatric illness
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Economic Burden
The economic burden associated with alcohol misuse alone is approaching $200 billion annually, far exceeding the cost associated with other medical conditions such as cancer ($107 billion) and heart disease ($96 billion).
When combined with other drugs the economic burden is close to $400 billion annually.
Gruel and Rehm. 2003
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MGH Facts/Figures
At MGH Outpatient Addiction Services, approximately 2
out of 3 patients have co-occurring mental health and
substance use disorder diagnoses
Inpatients with an SUD primary or secondary diagnoses
had a LOS of 2.5 days longer than those without
Patients with alcohol use issues comprise 5% of all ED
visits, but 7.2% of ED bed hours, or 3 beds in any 24
hour period
32% admitted, compared to 26% of other patients
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Starkly Reduced Dopamine Receptor Expression Observed in Brain Reward Centers in the Striatum
6Morgan, et al., 2002, Nat Neurosci
Reduced D2 Receptor Expression Experimentally Induced by Social Stress and Correlation with Cocaine Self Administration
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3-D Iso-surface Representation of Amygdala in Cocaine Addiction Showing 23% Volume Reduction
Patients
Normal Controls
AnteriorPosterio
r
Superior
Right Lateral Ventricle = red
Left Lateral Ventricle = green
Common
Right Amygdala
Makris et al., 2004 Neuron
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Drug Administration/Drug-Seeking BehaviorFailed impulse suppression
Euphoria/Positive Reinforcementactivated reward pathways
NeuroadaptationsWithdrawal and ToleranceProtracted hedonic dysregulation
Drug Craving/Negative ReinforcementDysregulated reward pathways
Addictive agent
Drug-related cuesLimbic activation
Stress
Model of addiction
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Addiction
Addiction is a disorder of brain reward centers that normally insure the survival of organisms and the species
Drugs activate and dysregulate endogenous reward systems such that attention, motivation, behavior are directed away from
survival goals and toward drug-related cues
Dackis and O‟Brien, 2001
Defined by loss of control over intense urges to take the drug despite adverse consequences
Volkow and Fowler, Cereb Cortex 2000
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Onset
Substance use disorders typically have onset during adolescence and young adulthood and tend to have a chronic course without intervention - 90% of all adults with alcohol/drug dependence started using under the age of 18, half under the age of 15 (NSDUH, 2006) 75% of High School students have tried alcohol
Nearly 50% of seniors drink at least once a week
1 out of 4 seniors uses illicit drugs
1 out of 3 teens, age 14-17, have used an illegal drug more than once
Brain development continues well into mid-20‟s Sustained binge drinking may affect this process, may result in damage
to frontal-cortical regions
Early intervention and recovery management offers hope for shortening the intensity and course of the illness
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Age at Onset of DSM-IV Drug Abuse and Dependence
Compton et al. Arch Gen Psychiatry/ Vol 64, May 2007; 45(11): 1294 - 1303
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Who is Vulnerable?
Adolescents
40-60% of vulnerability for addiction genetically influenced
Addiction is more prevalent in people who have the following
childhood psychiatric disorders:
Depression and Bipolar Disorder*
Anxiety
Schizophrenia
Post-Traumatic Stress Disorder
Attention Deficit Hyperactivity Disorder
Conduct Disorder*
* Denotes largest risk factor: Over half develop substance abuse
N. Volkow, 2007, Director National Institutes on Drug AbuseGoldman, et al; ‘05 Nature Rev. Gen.; Hiroi, et al; ‘05 Mol Psychiatry
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Striatum & Hippocampus
Medial Wall
Prefrontal structures
Substances of Abuse are Deleterious in Adolescent Brain Development
Negative CNS effects of chronic alcohol use in teens:- Learning- Information recall, memory (verbal, nonverbal)- Vocabulary- Sleep (mood,
attention)
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Relationship between Mental Health and Substance Use Disorders
Complex, multifaceted
Genetics/ neurobiological
Affected by multiple systems of adolescent/young adult life Family, Community/ School, Peers, Media
Life stresses, academic and social issues
Dynamics-self medication
Changes with maturation, normal development
Substance use can worsen the severity of pre-existing mental health conditions; untreated mental health issues exacerbate substance use
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Clinical Imperative
Substance Use Disorders are Highly Prevalent,Under-recognized and Under-treated
Screening is fast and effective
Even brief intervention can effect salutary change
Early Intervention is optimal
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What Can Be Done?
Treatment works; extensive models are best suited to the nature of addiction
Effective treatments exist:
Pharmacotherapy
Rarely Prescribed
Cognitive-behavioral therapy
Motivational Interventions
Community Reinforcement Model
12-step facilitation
Family therapy
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Innovative Models of Care
Extensive models are best suited to the nature of addiction
“Aftercare” – Continuing Care – Treatment
Case monitoring
Recovery management
Assertive Continuing Care
Mutual Help Groups/Peer Support
Program Evaluation
Science-based practice
Practice-based science
Intermediate Outcomes/Theory
Provides for systematic evaluation; identification of patient subgroups/non-responders
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Treatment Challenges - Stigma
Conceptualized as a disorder of „Free Will‟
“substance abuser”
Perhaps even more than other mental illness, patients with substance use disorders feel strong sense of shame/embarrassment, and self-loathing
Shame associated with substance use creates a barrier to accessing treatment and disclosure/open communication
Substance use disorder is a chronic health condition similar to hypertension, diabetes and yet is not treated as such
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Is Substance-Related Treatment Worth Its Cost? Addiction treatment is highly cost-effective
Every $1 invested in addiction treatment programs yields a $4-7 saving in reduced drug-related crime, criminal justice costs, and theft alone.
When health care savings are included, total exceeds costs by ratio of 12 to 1
Major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents.
Measuring and Improving Cost, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES, NIH, NIDA 1999.