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Transcript of 1 A New Paradigm for Recovery University of Florida Scott Teitelbaum, M.D. FASAM, FAAP, Vice...
1
A New Paradigm for RecoveryUniversity of Florida
Scott Teitelbaum, M.D. FASAM, FAAP, Vice Chairman & Chief of Addiction Medicine
ASAM Definition of Addiction
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV
0.00.0
0.20.2
0.40.4
0.60.6
0.80.8
1.01.0
1.21.2
1.41.4
1.61.6
1.81.8
55 1010 1515 2020 2525 3030 3535 4040 4545 5050 5555 6060 6565
THCTHCALCOHOLALCOHOL
TOBACCOTOBACCO
7070 7575
National Epidemiologic Survey on Alcohol and Related Conditions, 2003
% in
eac
h ag
e to
dev
elop
fir
st-ti
me
depe
nden
ce
Age
Addiction is a Developmental Disease
Gateway Drug
Statistics Those aged 18-25 most likely to use illicit
drugs. Age at which an adolescent begins to use
alcohol is a predictor of later alcohol and drug problems, particularly if first use is before age 15.
60 % of persons aged 18-25 have tried an illicit drug before
34% have tried an illicit drug in the past year 20% have tried an illicit drug in the past month
National Household Survey on Drug Abuse, 2005
Winter, 2013: SAMHSA
Between 2010 & 2011, non-medical use of prescription drugs declined among young adults ages 18-25 (from 2M to 1.7M; 14%)
Success of national efforts to address prescription drug problem
BUT… marijuana and heroin use increased
Access predicting introduction to use
As to obtaining prescription opiates, >50% of 12th graders were “given the drugs or bought them from a friend or relative”
Despite age group’s internet facility, number purchasing opioids on internet was negligible
Inherent trust of prescribed drugs
Less harmful because medically administered
Dosage regulated by medical profession and governmental oversight
Purity of substance and quality control
Might Not Meet Today’s FDA Standards
Young adults commonly transitioning from prescription opioids to heroin Availability of heroin + scarcity of Rx opiates Price of heroin
2010 to 2011, heroin overdose deaths increased 47% in one year (2,789 to 4,102) across entire age spectrum of U.S. population
36 % of those aged 19-28 report having consumed more than 5 drinks in a row in the preceding 2 weeks
Hippocampal volumes were found to be significantly smaller in those youths with an Alcohol Use Disorder
Smaller hippocampal volumes with longer-duration AUD
May effect brain structures critical to learning and memory formation
National Institute on Alcohol Abuse and Alcoholism
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, 2005. Partnership for a Drug Free America. 17th annual study of teen drug abuse.
Designer Drugs:
What’s New & Ongoing
GG
Special KSpecial K
SpeedSpeed
Crystal
Crystal
DMTDMT
BZPBZP
“Its All About Sensation”
Smell sensation is intensified by the high, resulting in a pleasurable effect from the fumes
Vicks inhalants, cough drops, surgical masks with med rub
Serotonin rush
Neurotoxicity of DrugsNeurotoxicity of Drugs
substantia nigra substantia nigra
locus ceruleus locus ceruleus
What’s happening at the cellular level?
What’s happening at the cellular level?
Designer Cannabinoids
This raising suspicion that these products may contain unknown chemicals that produce effects similar to cannabinoids In Dec. 2008 a synthetic cannabinoid JWH-018
was discovered in the herbal smoking blend Spice®
Other synthetic cannabinoids: HU-210, HU-211, and JWH-073 were also discovered and are likely responsible for the psychoactive effects in these products
Designer Cannabinoids
Synthetic cannabinoids can produce the same or even more powerful effects as those produced by the cannabinoid molecules in the marijuana plant
They also have very different molecular structures than the plant cannabinoids
19
Nov. 4, 2002
Marijuana Perceived Marijuana Perceived Risk vs. UseRisk vs. Use
Adolescents with AUD still appeared to have reduced neuropsychological functioning after 3 weeks of abstinence
“Arrested Development”
Normal risk-taking behaviors magnified with the addition of a substance
Pre-frontal cortex (responsible for logical thought, judgment, decision making) not fully formed until mid- 20’s. Substance use can impair healthy brain development
Emotional coping skills often delayed as a result of substance use
Healthy Heart
Decreased Heart Decreased Heart MetabolismMetabolism in in Heart Disease PatientHeart Disease PatientDecreased Heart Decreased Heart MetabolismMetabolism in in Heart Disease PatientHeart Disease Patient
ADDICTION IS A DISEASE OF THE BRAIN Like other diseases, it affects tissue function
Control Cocaine Abuser
Decreased Brain Metabolism in Drug Abuse Patient
Sources: From the laboratories of Drs. N. Volkow and H. SchelbertSources: From the laboratories of Drs. N. Volkow and H. Schelbert
High
Low
25
Hypofrontality in Cocaine Dependent Hypofrontality in Cocaine Dependent PatientsPatients
Reduced Metabolic activity at baseline in cocaine dependent subjects
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
26
The Memory of DrugsThe Memory of Drugs
Nature VideoNature Video Cocaine VideoCocaine Video
Front of Front of BrainBrain
Back Back of of
BrainBrain
AmygdalaAmygdalanot lit upnot lit up
AmygdalaAmygdalaactivatedactivated
Brain areas where volumes are smaller in adolescents
than young adults
During Adolescence the COGNITION-EMOTION
Connection is Still Forming
During Adolescence the COGNITION-EMOTION
Connection is Still Forming
Amygdalo-cortical SproutingContinues Into Early Adulthood
Amygdalo-cortical SproutingContinues Into Early Adulthood
Childhood Adolescence Adult
Sowell, E.R. et al., Nature Neuroscience, 2(10), pp. 859-861, 1999. Cunningham, M. et al., J Comp Neurol 453, pp. 116-130, 2002.
The Adolescent Brain is Still Developing
Adolescent Brain
These brain changes are relevant to adolescent behavior Prefrontal cortex (PFC) is pruned and not fully
developed until mid-20’s Amygdala (and n.a.) show less pruning and
tend to dominate the PFC
Adolescent Brain Changes
These brain changes are relevant to adolescent behaviorPrefrontal cortex (PFC) is
pruned; not fully developed until mid-20’s
Amygdala (and n.a.) show less pruning and tend to dominate the PFC
judgment
rewardsystem
amygdala
nucleusaccumbens
prefrontalcortex
Ken Winters, Ph.D.
Judgment vs. Reward
Amygdala = Reward System
Prefrontal Cortex =Judgment
Nucleus Accumben
s
Ken Winters, Ph.D.
Adolescent Brain
This imbalance leads to... planned thinking
impulsiveness self-control risk-takingPFC
amygdala
I like to use drugs!
Ken Winters, Ph.D.
Drugs are
bad!
From “Oops” to Dependence
Ken Winters, Ph.D.
“Oops Phenomenon”
First use to “FEEL GOOD”
Some continue to compulsively use because of the reinforcing effects (e.g., to “FEEL NORMAL”)
Changes occur in the “reward system” that promote continued use
Ken Winters, Ph.D.
Reward System
The reward system is responsible for seeking natural rewards that have survival value seeking food, water,
sex, and nurturing Dopamine is this
system’s primary neurotransmitter
Ken Winters, Ph.D.
Addiction Liability
~10% who ever use marijuana become daily users
Conditional dependence – risk of dependence of those who ever use substance Marijuana 9% Ethanol 15% Cocaine 17% Heroin 23% Tobacco 32%
Age of Onset of First Alcoholic Symptoms Among Alcoholics
Age (years) %
10 – 14 3
15 – 19 39
20 – 24 22
25 – 30 15
30 – 34 5
35 – 40 4
Natural History of Primary Alcoholism
Years
Age at first drink 12-14
Age at first intoxication 14-18
Age at first minor problem 18-25
Usual age of onset 23-33
Usual age of treatment entry 40
Usual age of death* 55-60* Leading cause: Heart or liver disease, Cancer, Accidents, Suicide
Socio-culturalSocio-cultural
EnvironmentalEnvironmentalPsychologicalPsychological
Influences susceptibility Influences susceptibility to drug usageto drug usage
The processes The processes that initiate and that initiate and maintain maintain alcoholism are alcoholism are regulated by regulated by interactions interactions among nerve among nerve cells in the braincells in the brain.
BiologicalBiological
42NIH/NIDA
Cannabis Abuse and the Adolescent Brain
Epidemiology
• Marijuana is the most widely used illicit drug both in the U.S. & world-wide
• More than 75 million (over 34%) of Americans 12 years or older have tried it at least once & almost 19 million have used it in the past year
• Average age of 1st use has been declining:- 12-17 year olds – 13.6 years
- 18-25 year olds – 16 years
• While most discontinue marijuana by their mid-20’s, a subset maintain daily, long-term use
Marijuana- Potency D.E.A. Seizure Data
Marijuana- Chronic Effects
Behavioral- “Amotivational syndrome” Cognitive- impaired memory/attention Psychiatric- rare but real permanent psychosis
(likely “flips” those predisposed) Respiratory- cancer, COPD Cardiovascular- HTN, tachycardia, MI Decreased Immunity Teratogenicity- unknown extent of fetal
neurotoxicity Reproductive- decreased testosterone, sperm
count/motility; inhibits prolactin, LH, GH
Medical Utility of Marijuana
Some efficacy shown in many areas However no studies are available comparing
marijuana to best known available treatments
Also, smoking as a delivery mode is undesirable because of toxicity and variability in dosing
CANNABIS AND THE BRAIN
Increased risk of schizophrenia
Reduced Thalamus size
Decreased IQ
Decreased efficiency of executive function
Hyperactive reward centers
Relation Between Marijuana & other Drug Use
• Early age of onset is a major predictor both of continued frequent marijuana use & of likelihood of using other drugs (Denenhardt, et al. 2001, Lynsky, et al. 2003)
• The increased potency of marijuana may make the brain less responsive to endogenous cannabinoids. This may be especially marked in the still developing adolescent brain
• Combination of earlier onset & stronger marijuana may increase anxiety & apathy in teens & make other drug use more attractive
• Twin studies found early marijuana users had increased rates of other drug use and problems later on; odds of other drug use ranged from 2.1-5.2 times higher
Cannabis – most prevalent illicit drug identified in impaired drivers
Risk of involvement in a motor vehicle accident (MVA) increases 2-fold after cannabis smoking.
Cannabis smoking increases lane weaving and impaired cognitive function.
Critical-tracking tests, reaction times, divided-attention tasks, and lane position variability all show cannabis-induced impairment.
Combining cannabis with alcohol enhances impairment, especially lane weaving.
Hartman RL, Huestis MA. Cannabis Effects on Driving Skills. 2013; 59(3): 478-492.
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.
Users typically start in late teens Use peaks in 20’s Use dramatically declines with association of
starting families and careers
10% will become daily users 20-30% will become weekly users
USER PROFILE
Challenges: YA score higher on pre-contemplation, lower
on contemplation, determination, action, motivation and readiness for change than older adults
Higher rates of treatment non-compliance and positive drug-test at discharge
American Journal of Drug and Alcohol Abuse, 2003
Treatment of Young Adults
Focus on the treatment readiness Work on development of healthier coping skills Work on improving interpersonal relationships Treatment of underlying psychiatric conditions
(common in early use of substances) Family therapy essential to challenge familial
patterns and educate loved ones
Approaches to Treatment of the Young Adult
Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses
Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses
00
1010
2020
3030
4040
5050
6060
7070
8080
9090
100100
Drug DependenceDrug Dependence
Type I DiabetesType I Diabetes
HypertensionHypertensionAsthmaAsthma
40
to 6
0%
40
to 6
0%
30
to 5
0%
30
to 5
0%
50
to 7
0%
50
to 7
0%
50
to 7
0%
50
to 7
0%
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.
Perc
en
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Pati
en
ts W
ho R
ela
pse
Perc
en
t of
Pati
en
ts W
ho R
ela
pse Addiction Treatment
Does Work
Treatment Today
Only 1 in 10 Americans who need treatment receive it
Of those that need it, approximately 95% don’t think they do
Of the 5% who believe they need it, 2/3 made no effort to obtain it
Less than 50% of those admitted to publically funded treatment successfully completed treatment
Acute Care Treatment as a Revolving Door
Of those admitted to the U.S. public treatment system in 2003, 64% were re-entering treatment including 23% accessing treatment the second time, 22% for the third or fourth time, and 19% for the fifth or more time (OAS/SAMHSA, 2005).
The Prevailing Acute Care Model
An encapsulated set of specialized service activities (assess, admit, treat, discharge, terminate the service relationship).
A professional expert drives the process. Services transpire over a short (and ever-shorter)
period of time. Individual/family/community is given impression at
discharge (“graduation”) that recovery is now self-sustainable without ongoing professional assistance (White & McLellan McLellan, in press).
Treatment (Acute Care Model) Works!
Post-Tx remissions one one-third, AOD use decreases by 87% following Tx, &, substance substance-related problems decrease by 60% following Tx (Miller, et al, 2001).
Lives of individuals and families transformed by addiction treatment.
Treatment Works, BUT…
POST-TREATMENT RELAPSE The majority of people completing addiction
treatment resume AOD use in the year following treatment (Wilbourne & Miller, 2002).
Of those who consume alcohol and other drugs following discharge from addiction treatment, 80% do so within 90 days of discharge (Hubbard, Flynn, Craddock, & Fletcher, 2001).
Treatment Works, BUT …
LOW ATTRACTIONOnly 10% of those needing treatment received
it in 2002 (SAMHSA, 2003) & access compromised by waiting lists (Donovan, et al, 2001).
HIGH ATTRITIONMore than half of clients admitted to addiction treatment do not successfully complete
treatment
Treatment Works, BUT…
LOW SERVICE DOSEInadequate doses of Tx contribute to risk of
relapse & future readmissions LACK OF CONTINUING CARE
Only 1 in 5 adult clients participated in continuing care (McKay, 2001) and only 36% of adolescents received any continuing care (Godley, Godley & Dennis, 2001)
Fragility of Early Recovery
Most individuals leaving addiction treatment are fragilely balanced between recovery and re-addiction in the hours, days, weeks, months, and years following discharge.
Recovery and re-addiction decisions are being made at a time that service professionals have disengaged from their lives, while many sources of recovery sabotage are present.
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
Phase I: What are Physician Health Programs (PHP)?
Not treatment, disciplinary, law enforcement or licensing organizations
Active care managers overseeing long-term care including drug testing They select and communicate with caregivers
including treatment programs, monitoring organizations and doctors/therapists/counselors
Physicians who enter PHP care face serious consequences for any noncompliance including any alcohol or drug use
PHP Long-Term Drug Test Results
Over the course of 5 years: 78% of all physicians
had zero positive drug tests
14% had only 1 positive drug test
3% had only 2 positive drug tests
5% had 3 or more
Lessons from the PHPS
1) Zero tolerance for any use of alcohol and other drugs2) Thorough evaluation and patient-focused (rather
than program-focused) care3) Prolonged, frequent random testing for both alcohol
and other drugs4) Effective use of leverage5) Defining and managing relapses: swift, certain and
meaningful consequences for any substance use and noncompliance
6) Goal of lifelong recovery rooted in the 12-Step fellowships
The New HIGHER Standard
The new paradigm has been successfully used in the criminal justice system – a population entirely different than physicians
New Paradigm in the CJS
Hawaii’s Opportunity Probation with Enforcement (HOPE) and South Dakota’s 24/7 Sobriety Project
These programs uphold the zero tolerance standard through drug tests and immediate, brief, incarceration for any drug use
Treatment is available on offender request but only required for individuals who demonstrate the need, using “Behavioral Triage”
12-Step participation is optional but encouraged
HOPE Drug Test Results
Over the course of one year: 61% of all HOPE
participants never had a single positive drug test
20% had only 1 9% had 2 10% had 3+
(Hawken & Kleiman, 2009)
24/7 Sobriety Drug Test Results
Over the average 111 days of participation: 55% never fail a test 17% fail only 1 time 12% fail only 2 times 16% fail three 3+
times
Summary of Findings
Zero tolerance with swift, certain, and meaningful consequences for any use of alcohol and other drugs – contrary to reasonable assumptions – leads to lower rates of use, higher rates of long-term success, and lower rates of failure
PHPs produced impressive results previously unseenHOPE and 24/7 Sobriety programs produced lower
rates of new crimes and lower rates of incarcerationUse of new concept of “Behavioral Triage” –
treatment is reserved for those who need it to stay clean and sober and for those who choose it
How Are These Programs Different?
Old Paradigm of care management: Infrequent or no testing; when testing occurs in
treatment, it is scheduled Responses are long-delayed and unpredictable – to
missed visits, missed tests, and positive tests Virtually all treatment is short-term (30 days, a few
months, or maybe a year) while the substance use disorders last for lifetimes
The 12-Step programs are underused or not used at all in many current treatment programs
Effective substance treatment
Typically incorporates many components, each directed at a particular aspect of the illness
Must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society
Need NOT be voluntary to be effective!
Wisdom of involuntary treatment order
21% of Americans ages 18-25 have substance use disorder to severity requiring treatment 96% of these addicted individuals do not
perceive the need for assistance
**Courts provide critical access to care
What is recovery? A working definition from the Betty Ford
InstituteThere 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.
The Betty Ford Institute Consensus Panel
Journal of Substance Abuse Treatment 2007; 33: 221-228.
The Betty Ford Institute Consensus Pane (Dr Gold was a member of this panel )Journal of Substance Abuse Treatment , 2007; 33:221-228.
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
While science has taught us that addiction is a hijacking of the brain, recovery must involve healing of the heart
and the soul.
Drug Use Addiction TreatmentNormal
Recovery
The Great ChallengeFor Addiction Treatment in 21st
Century
To Integrate:
Addiction Medicine, Psychiatry and Spirituality in the Treatment of
Substance Use Disorders.
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