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Title&Below&please&list&the&title&of&this&resource.& &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
!Addiction!Recovery!Management!
!Author&Below&please&list&the&author(s)&of&this&resource ."
!Kevin!McCauley,!MD!
!
Citation&Below&please&cite&this&resource&in&APA&style.&For&guidance&on&citation&format,&please&visit&
http://owl.english.purdue.edu/owl/resource/560/01/&
!McCauley!MD,!Kevin.!(2011).!Addiction"Recovery"Management![PowerPoint!slides].!Retrieved!from!
www.instituteforaddictionstudy.com!!
!
Summary&Below&please&provide&a&brief&summary&of&this&resource.&If&an&abstract&is&available,&feel&free&to©&and&paste&it&here.&
!This!power!point!presentation!highlights!how!the!disease!of!addiction!works!and!the!brain!functions!and!
reactions!that!accompany!the!disease.!The!slides!go!on!to!explore!the!five!theories!of!addiction.!He!then!
reviews!methods!of!treatment!followed!by!an!exploration!of!recovery!capital,!recovery!management,!
recovery!resource!mapping,!and!recoveryoriented!systems!of!care.!
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Kevin T. McCauley, M.D.The Institute for Addiction Study
Salt Lake City, Utahwww.instituteforaddictionstudy.com
(435) 659-6293
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The most evil disease imaginable
Wouldnt look like a disease at all (nearly invisibleepidemiologically)
Genetic, but with variable penetrance (genotype phenotype) Repulsive symptoms easily confused with willful badness Self-deception as a clinical feature Poor prognosis if untreated, but some will get better (inexplicably) Chronic and relapsing (not acute, nor cured) Culturally & politically divisive (would tap into societys deepest
prejudices, stigma, superstitions and attack its core values)
Maximally economically destructive (solutions based on greed &exploitation)
Would cover its tracks (by blaming other diseases) Would only submit to weird solutions: peer support, patient
accountability, personal evaluation, and spiritual growth (not just amedication or surgery)
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The Key Parts of the Limbic Brain
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Orbitofrontal Cortex (OFC) Decision-making guided by
rewards
Integrates sensory andemotional information fromlower limbic structures
Flexible assignment ofvalue to environmental
stimuli to motivate orinhibit choices & actions
Self-monitoring and socialresponding
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Anterior Cingulate Cortex (ACC)
Works with OFC:decision-making basedon reward values
But also generates newactions based on past
rewards/punishments
Appreciation andvaluation of social cues
MRI: active in tasksrequiring empathy andtrust
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Prefrontal Cortex (PFC) Behavioral regulation Reflective decision-
making Inhibition of socially
inappropriate actions
Emotional and sensoryintegration
Planning complexbehaviors
Personality expression
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Drugs work first inthe
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The Midbrain is the brain Not conscious Acts immediately, nofuture planning or
assessment of long-termconsequences
A life-or-deathprocessing station
for arriving sensoryinformation
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In addiction, the drug hijacks the survival
hierarchy and is so close to actual survival that it
is indistinguishable from actual survival
2. EAT!3. KILL!4. SEX !
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Addiction is a disorder in the brains
Reward (Hedonic) SystemIt is a broken
pleasure sense
in the
brain
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Addiction is a disorder of
5. CHOICE (motivation)
4. STRESS (anti-reward system)
3. MEMORY (learning)
2. REWARD (hedonic system)
1. GENES (vulnerability)
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Five Theories of Addiction
1. Genetic Vulnerability (Schuckit et al)
2. Incentive-sensitization of Reward (Robinson & Berridge)
3. Pathology of Learning & Memory (Hyman, Everitt & Robbins)
4. Stress and Allostasis (Koob & LeMoal)5. Pathology of Motivation and Choice
(Kalivas & Volkow)
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Addiction Neurochemical #1: Dopamine
All drugs of abuse and potential compulsivebehaviors release Dopamine
Dopamine is first chemical of a pleasurableexperience - at the heart of all reinforcingexperiences
DA is the neurochemical of salience (it signalssurvival importance)
DA signals reward prediction error Tells the brain this is better than expected
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Incentive-Sensitization(Robinson & Berridge)
Distinguished between a liking and a wantingrole for Dopamine (its more about wanting)
Created hyper-dopaminergicDopamine Transporterknock-down mice (mice with increased synapticDopamine)
Observed increased intake of reinforcing substancesin these mice and greater thwarting of obstacles to
get them (i.e. more wanting)
But did not observe greater liking of thesesubstances by these mice
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Alcohol & Sedative/Hypnotics Opiates/Opioids Cocaine Amphetamines Entactogens (MDMA) Entheogens/Hallucinogens Dissociants (PCP, Ketamine) Cannabinoids Inhalants Nicotine Caffeine Anabolic-Androgenic Steroids
Food (Bulimia & Binge Eating) Sex Relationships Other People
(Codependency, Control)
Gambling Cults Performance
(
Work-aholism
)
Collection/Accumulation (Shop-aholism)
Rage/Violence Media/Entertainment
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Addiction Neurochemical #2: Glutamate
The most abundant neurochemical in thebrain
Critical in memory formation & consolidation All drugs of abuse and many addicting
behaviors effect Glutamate which preservesdrug memories and creates drug cues
And glutamate is the neurochemical ofmotivation (it initiates drug seeking)
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DOPAMINE (DA) GLUTAMATE (Glu)
All drugs of abuse andpotential compulsivebehaviors INCREASE DA
Reward saliencethis is important!I really want this!Rostral (toward the nose)projections:
PFC < NA < VTA
All drugs of abuse andpotential compulsivebehaviors EFFECT Glu
Drug memoriesDrug seekingOK, Ill rememberFine, go and get itCaudal (toward the tail)projections:
PFC > NA
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The hypofrontal/craving brain state represents
and imbalance between 2 brain drives
Cortico-Striatal Circuit
STOP! Organized, Attentive Sensitive to consequences Well-planned Socially appropriateTHERES TOO LITTLE OF THIS
Amygdalar-Cortical Circuit
GO! Impulsive Non-reflective Poorly conceived Socially inappropriateTHERES TOO MUCH OF THIS
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: Pleasuredeafness(the patient is no longer able to derive normal
pleasure from those things that have beenpleasurable in the past)
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Relapse Three things that are known to evoke relapse in
humans:
1. Brief exposure to drug itself (DA release) 2. Exposure to drug cues (GLU release)
3. Stress (CRF release)
(example of a dangerous relapse-triggering behavior:
talking about drugs (cues) with other newly-soberaddicts in treatment (stressed) while smoking (DA surge)
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Craving / Drug Seeking Not quite as conscious as deliberative acts More automatic - like driving a car home
from work without really thinking about it
I was vaguely aware that what I was doingwas not too smart
There I was again with a drink in my handthinking that this time things would be
different
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damage toOrbitofrontal Cortex (OFC)
Causes a loss of a crucialbehavioral guidance system
Responses are impulsiveand inappropriate
Deficits of self-regulation Inability to properly assign
value to rewards (such as
money vs. drugs)
Tendency to choose small &immediate rewards overlarger but delayed rewards
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damage toAnterior Cingulate Cortex (ACC)
Just as with OFC damage:causes a loss of a crucialbehavioral guidance
system Inflexibility/Inability to
respond to errors in thepast with regard to
rewards/punishments
Deficits in socialresponding due todecreased awareness of
social cues
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damage toPrefrontal Cortex (PFC) Failure of executive
function
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Hypofrontality Bechara: research on pts with vmPFC & OFC lesions Myopia for the future - cognitive impulsiveness- these patients prefer immediate butdisadvantageous rewards over rewards that are
delayed but advantageous in the long run
- their decisions are guided primarily by immediate
prospects and are insensitive to positive or negativefuture consequences (rewards or punishments)
- they deny or are unaware of their problem
Scans of vmPFC patients are similar to Sub Abuse pts
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It fails to take into account The Choice Argument measures addiction
only by the addict
s external It ignores the inner of the patient You dont actually have to have drug use for
the defective physiology of addiction to beactive
The addict cannot choose to not
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So how DO we break the hold
ofcravingandturn the FrontalCortex backon?
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misperception ofthe hedonic aspects ofthe drug
And attribution of survival
salience to the drug onthelevel of the unconscious
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The drug takes onpersonal meaning
The addict develops anemotional relationshipwith the drug
The addict derives theirsense of self and exertsagency through the drug
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1. To give the addict
workable, credible
tools to proactively
2. For each individual
addict,
- and
displace the drug with
it
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Addiction is a disorder of
6. MEANING(spirituality?)
5. CHOICE (motivation)4. STRESS (anti-reward system)
3. MEMORY(learning)
2. PLEASURE (hedonic system)
1. GENES (vulnerability)
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AA: using NON - Rational Concepts (the fellowship of alcoholics) (Bills Story, etc.) (what it was like, what happened, and) (Keep coming back, it works) (The Promises) (the answer to all my problems)
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DSM-IV Criteria for Substance Dependence
(IM A TOWN DRUNK)
NABILITY (to cut down) ORE DRUG USED (than intended) LOT OF TIME (spent obtaining, using &
recovering from using the drug)
OLERANCE LD ACTIVITIES, FRIENDS & FAMILY MEMBERS
(given up in favor of the drug)
ITHDRAWAL EGATIVE CONSEQUENCES (have no effect on the
pattern of drug use)
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ASAM Addiction Definition (Aug 2011)A primary, chronic and relapsing brain disease
of reward (nucleus accumbens),
memory (hippocampus & amygdala),
motivation and related circuitry (ACC, basal
forebrain)
that alters motivational hierarchies such thataddictive behaviors supplant healthy, self-care
behaviors
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Addicts are patients! Addicts have the same rights as all patients All the ethical principles that apply to other
patients now also apply to addicts
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(Is there a group of addicts we dont punish?)
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Things we do for pilots:
Medical Detoxification Inpatient or Residential Treatment Aftercare: Immediately after treatment for
3-5 Years
A.A. Attendance Regular testing (monitoring) Return to duty Personal physician
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Treatment Outcome Variance in Pilots
Treated for Alcoholism:
The United States Navy enjoys a 95-97% return to flying
status rate in its pilots treated for alcoholism.
- Joseph A. Pursch, M.D.
Since the inception of its impaired pilot program inconjunction with the FAA and ALPA EAPs, UAL has an 87%
return to flight status rate in pilots treated for alcoholproblems. - Stanley Mohler, M.D.
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Problems with the Disease (Acute Care) Model
Reductive
Materialistic
Expensive, dramatic, late-stage, disruptive
interventions in lieu of a more preventive
Results in episodic, reactive, fragmented,poorly-targeted care
Cannot address meaning, or spiritual/community solutions
Strips patient of power (and hands that powerto the doctor)
Encourages the sick role (fostersdependency, absolves responsibility)
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Benefits of inpatient care
Medical detoxification
Baseline psychiatric evaluation & treatment
Intensive daily structure
Solidification of abstinence
Removal from codependent family/socialsystem
Incapacitation of usePatient takes it seriously
Finney et al. Addiction 1996 91(12), 1773-1796
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Chronic DiseasesAsthma
Diabetes mellitus
Chronic Obstructive Pulmonary Disease (COPD)
Post-chemotherapy/Cancer
Hepatitis B/C
HIV/AIDS
Major Depression
Chronic Pain
Lupus Erythematosis
Cystic Fibrosis
Alzheimers Disease
Kidney Disease
Heart Disease/Post-MI
Hypertension
Rheumatoid Arthritis
Epilepsy
Irritable Bowel Disease
ADHD
Addiction/Recovery
Migrainosis
Anticoagulation Therapy (post-DVT, AtrialFibrillation)
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advantages of a
Chronic Care
Model
Non-urgent
More efficient and cost-effective
Preventive
Based on continuous, healing relationships
Provides services across the continuum of care forlife
Centralized, local (no aircraft needed)
Family-centered
Informational (EMRs > NHII > research)
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Disease Management
Disease Management is a system of coordinated healthcare interventions and
communications for populations with conditions in which
patient self-care efforts are significant.
Goal: improving quality of life and reducing healthcare costs forindividuals with chronic diseases by preventing or minimizing the
effects of the disease through integrative care
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Disease ManagementTargets people with chronic conditions
Located outside the point of care
Personal communications (usually by telephone)
Multidisciplinary team approach
Linkage with community resources
Patient education and self-management support
Close monitoring of symptoms & reporting to clinical team
Goal is to minimize or prevent complications, relapses, re-hosp.
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examples of Disease Management
Nurse outreach (telephony, home visits)
Action planning, Symptom reporting
Health coach advocacy, encouragement
Remote home monitoring or daily testing
Internet interfaces, questionnaires
Physician practice supportRisk assessment, stratification, targeting of
intervention
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What Disease Management looks like for
Daily Fasting Blood Glucose testing (and recording)
Intensive (Flexible) Insulin therapy with MDI/pump
Periodic Hemoglobin A1C testing to check long-term glycemic control
Annual Ophthalmologic Exam
Periodic Podiatric Exam/Foot Care
Diet, Weight Control, Exercise
Monitoring serum cholesterol and lipid profile
Diabetes patient support groups
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What Disease Management looks like for
Community-based Sober Living/Residential Support
Monitoring (non-random drug testing)
Group Therapy/Cognitive-Behavioral Therapy
Peer-Based Recovery Support Groups (AA, etc)
Addictionologist/Addiction Psychiatrist
Web-based Assessment Tools
Call centers/Phone counseling
Occupational/Vocational Assistance
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Recovery Capital(Granfield & Cloud)
Recovery Capital is the sum total of all thepersonal, social, and community resources a
person can draw on to begin and sustain their
recovery from drug and alcohol problems.
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Recovery Management
www.facesandvoicesofrecovery.org/pdf/White/recovery_monograph_2008.pdf
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The
Blueprint
Studies Dupont RL, McLellan AT, White WL, Carr G, Gendel M,
Skipper GE. How are physicians treated? A national survey
of physician health programs. Journal of Substance Abuse
Treatment 2009 Jul; 37(1): 1-7.
Dupont RL, McLellan AT, White WL, Merlo LJ, Gold MS.Setting the standard for recovery: physicians health
programs. Journal of Substance Abuse Treatment 2009
Mar; 36(2): 159-71.
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Characteristics of Physician Health Programs
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Physician Health Programs (PHPs)
Relapse: 22% had one relapse over five years
Of those, only 26% had a repeat positive test
At the end of five years:
71% were working and licensed 18% were retired, died or licenses revoked
(Dupont RL, McLellan AT, Skipper GE. How are physicians treated? A national survey of physician health programs. J Sub Abuse Tx (2009)37:1-7.
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Tips for the First Year of Recovery
1. Residential Treatment (Inpatient or Residential Day)
2. Immediate Aftercare following Residential Treatment
3. Sober Living Environment
4. Ninety A.A. meetings in ninety days (90x90)
5. Automatic Relapse Plan
6. Testing
7. Rapid but Gradual Return to Duty
8. Addictionologist
9. Medication
10. Fun! (Hedonic Rehabilitation/Pleasure Therapy)
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Relapse Plan
DO NOT PANIC! Have an Automatic Relapse Plan(previously agreed upon/no discussion)
Detox (incapacitation) Return to Treatment (residential vs. outpatient) Review Testing Protocol Validate success
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Daily Testing RegimenCocaineAmphetamine
MethamphetamineTHC
Methadone
BuprenorphineOpiates
Oxycodone
Propoxyphene
PCPBarbiturates
Benzodiazepines
Alcohol (breath-analysis)
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Two Kinds of Tests in Addiction Medicine
SCREENING Tests
Immunoassay
Very sensitive
Not very specific
Not an insignificant false
positive rate
CONFIRMATION Tests
GC/MS
Very, very specific
Not very sensitive
Forensic standard
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Addictionologists
Certified by the American Society ofAddiction Medicine
Understand the special needs of recoveringpatients Not likely to make stupid mistakes Doctors who LIKEaddicts, Offices that are
safe places
www.asam.org www.csam-asam.org
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Controlled Substances Protocol All meds in safe (no loose pills) Safe behind locked door, combination
changed monthly
Med recording sheets/Pill Count sheets Staff tested weekly Communication with prescribing physician
(rationale for Rx known)
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Cost per month (Orange County numbers)1. Therapist $150/session x 4 = $600
2. Addictionologist/Psychiatrist $200/visit x 2 = $400
3. Mens/Womens Therapy Group $60/group x 4 = $240
4. Testing $40/test x 10 = $400 - $500
5. Medications (prn) varies6. Aftercare/Outpatient Program varies (may be free)
7. Sober Living Environment $500 - $1500 (& up) $1500
8. Twelve-step meetings free
$3,000 - $4,000
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National Outcome Measures (NOMs)
Abstinence Employment/Education Crime & Criminal Justice Stability in Housing Access/Capability Retention Social Connectedness Perception of Care Cost Effectiveness Use of Evidence-based Practices
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Population served
Time Period: 2 years Number of Residents: 39 men
Range of Duration of Stay:14 to 267 days
Average Length of Stay: 98.0 days Age distribution: x = 28.9, bimodal
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Performance data: Total Delivery:3619 resident-days Days Positive Test: 81 days (2.3%) Days Intoxicated: 83 (2.3%) Relapsed post-Tx: 48.7% Readmit Rate: 20.5%
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LMM Outcomes
39 residents over two-year period 3615 resident-days of service delivered average length of stay was 96.9 days (range: 14 to 287) 34.4% stayed longer than originally intended 40.6% stayed shorter than originally intended 98% of resident-days were abstinent by drug and alcohol screen 23% re-admission rate (half for relapse, half for relapse prevention) 23% employed on admission 61% employed or in school at time of discharge 48 ROSC linkages created and utilized 2 DUI arrests, no probation violations 90.6% of discharged residents transitioned to stable living situations
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