THE DISEASE OF

ADDICTION:

A Primer

The 10th Annual Kinship Conference for

Grandparents and Relatives

South Burlington, Vermont

9 September 2014

3 BASIC QUESTIONS

AT THE KITCHEN TABLE

1. Why don’t they just stop?

2. Does treatment really work?

3. How does treatment work?

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.”

• “Equal opportunity destroyer”: not

correlated with gender, education,

professional status, or sociopathy

• BIO-BEHAVIORAL change from

voluntary control to compulsive &

uncontrollable

THE FACTS

ADDICTION:

SIMPLY DEFINED

Continued use despite

consequences.

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

BRAIN MOLECULAR TARGETS OF

DRUGS AND ALCOHOL

??Inhalants

Serotonin receptors

Serotonin receptors

NMDA receptors

NMDA receptors

Hallucinogens

LSD

MDMA

PCP

Ketamine

Dopamine transporters

Dopamine/NE release

Stimulants

Cocaine

Amphetamines

Opioid receptorsOpioids

Cannabinoid receptorsMarijuana/THC

GABA receptors

GABA receptors

Depressants

Barbiturates

Benzodiazepines

Nicotinic Ach receptorNicotine

Adenosine ReceptorsCaffeine

Classes of Drugs Primary Target

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

Alcohol Targets

SUBSTANCE USE DISORDER

Diagnosis associated with:

• Alcohol

• Cannabis

• Phencyclidine

• Other hallucinogens

• Inhalants

• Opioids

• Sedatives, hypnotics, or anxiolytics

• Stimulants

• Tobacco

• Other (or unknown)

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:

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.

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.

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.

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.

SUBSTANCE USE DISORDER

• 11 Criteria

• Severity level:

0-1 = No Diagnosis

2-3 = Mild (~ Abuse)

4-5 = Moderate (~ Dependence)

6+ = Severe (~ Addiction)

ADDICTION SYMPTOMS:

TRAJECTORIES OF ONSET

BY SUBSTANCE

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.

ADDICTION TREATMENT:

COMPARISON WITH OTHER

CHRONIC DISEASES

Disease Inherited Outcome Relapse

HBP .25 - .50 60% 50 - 70%

Diabetes .80 60% 30 - 50%

Asthma .36 - .70 40% 50 - 70%

Addiction .34 - .52 40 - 60% 30 – 50%

(McLellan et al, JAMA, 2000)

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

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 evidence-

based 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”

THE ACUTE CARE MODEL

NTOMS Sample of

250 Programs

TREATMENT

PATIENT WITH SYMPTOMS

PATIENT WITHOUT SYMPTOMS

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

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

If addiction is a chronic disease

then:

We are neither treating nor evaluating

the effectiveness of its

treatments correctly.

0

2

4

6

8

10

Pre During During During Post

OUTCOME STUDIES WITH

HYPERTENSION

0

2

4

6

8

10

Pre During During During Post

OUTCOME STUDIES WITH

ADDICTION

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.

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

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.

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

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

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

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

4.5%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

13%

14%

15%

Household

(OR=1.00)

Less than 1

(OR=2.87)

1-3 Years

(OR=1.61)

4-8 Years

(OR=0.84)

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

13%

14%

15%

Household

(OR=1.00)

Less than 1

(OR=2.87)

1-3 Years

(OR=1.61)

4-8 Years

(OR=0.84)

4.5%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

13%

14%

15%

Household

(OR=1.00)

Less than 1

(OR=2.87)

1-3 Years

(OR=1.61)

4-8 Years

(OR=0.84)

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

13%

14%

15%

Household

(OR=1.00)

Less than 1

(OR=2.87)

1-3 Years

(OR=1.61)

4-8 Years

(OR=0.84)

Source: Scott, Dennis, Simeone & Funk (2011)

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%

3.8%

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.”

3 BASIC QUESTIONS

AT THE KITCHEN TABLE

1. WHY DON’T THEY JUST STOP?

2. DOES TREATMENT REALLY WORK?

3. HOW DOES TREATMENT WORK?

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 03766

mark.p.mcgovern@dartmouth.edu