Eat, Drink, Have Sex, (Use Drugs)

The compulsion and perseveration of the dopamine pathways is critical The compulsion and perseveration of the dopamine pathways is critical. Lizard brain: drink, have sex, find food. You want to be obssessed with those thoughts in order to promote your survival Humans have been on earth 200,000 years, maybe ancient versions of us are found 2 million years ago.

Normal day – 50 U of dopamine. Great day – Happy day = 100 U Sex = 102 U Great food = 90 U. Terrible day – refuse to go to work day, hide under your blankets day = 30

Most people with depression, dysthymia are sitting at 30 U of dopamine every day

Brain recognizes that having 1000 – 1500 U of dopamine is crazy and it rapidly starts dialling down release, production, receptors. The NA gets broken. Most people with addiction are sitting at 30 U. They can barely leave the house. Make it to appmnts. Irritable, swearing, unpleasant, ungrateful, poorly kempt, bad attitude.

Just as we turn down the volume on a radio that is too loud, the brain adjusts to the overwhelming surges in dopamine (and other neurotransmitters) by producing less dopamine or by reducing the number of receptors that can receive and transmit signals. As a result, dopamine's impact on the reward circuit of a drug abuser's brain can become abnormally low, and the ability to experience any pleasure is reduced. This is why the abuser eventually feels flat, lifeless, and depressed, and is unable to enjoy things that previously brought them pleasure. Now, they need to take drugs just to bring their dopamine function back up to normal. And, they must take larger amounts of the drug than they first did to create the dopamine high - an effect known as tolerance. 

Just as we turn down the volume on a radio that is too loud, the brain adjusts to the overwhelming surges in dopamine (and other neurotransmitters) by producing less dopamine or by reducing the number of receptors that can receive and transmit signals. As a result, dopamine's impact on the reward circuit of a drug abuser's brain can become abnormally low, and the ability to experience any pleasure is reduced. This is why the abuser eventually feels flat, lifeless, and depressed, and is unable to enjoy things that previously brought them pleasure. Now, they need to take drugs just to bring their dopamine function back up to normal. And, they must take larger amounts of the drug than they first did to create the dopamine high - an effect known as tolerance. 

Two people come to the ER: one had acute STEMI and the other an overdose. One gets brought to cath lab, ICU, admitted for 5-7 days, brought to cardiac rehab, started on 4 medicines, SW consult. The other is given dose of Narcan and kicked out the door. The 30, 60, 90 day mortality higher for the OD than the acute MI. One may be 24 with 60 more years of life and the other 84. Completely different care.

American Society of Addiction Medicine (ASAM) Addiction Definition, April 2011 Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry Affects neurotransmission such that addictive behaviors replace healthy self-care related behaviors Genetics account for 50% of addiction development Significant self-deception Disruption of healthy supports and problems in interpersonal relationships History of trauma or stressors that overwhelm an individual’s coping abilities The presence of co-occurring psychiatric illness Distortion in meaning, purpose and values that guide attitudes, thinking and behavior The effects to the brain allow external cues to trigger craving and drug use Persistent risk of and/or recurrence of relapse Impaired executive function so that perception, learning, impulse control., compulsivity and judgment are impaired.

Compulsive Use Loss of Control Continued Use Despite Harm Cravings 4 C’s of Addiction Compulsive Use Loss of Control Continued Use Despite Harm Cravings

Trauma Genetics Early Use Poor Mental Health

Genetics Account for 50% of Risk of Addiction

Addiction is a Developmental Pediatric Disease Adolescents are the healthiest cohort in the population in terms of organic disease but, at the same time, they experience relatively high rates of mortality and morbidity due to their behavior, including the use of alcohol.  Across many species including humans, adolescence is a time of heightened risk-taking and for many young people in our society, some of that risk-taking involves alcohol use.  Further, adolescence is a period of increasing socialization often involving alcohol.  For some, the increased social demands of adolescence may be accompanied by increased anxiety heightening the risk for alcohol use.  In this way, alcohol use has become intertwined with the normal developmental processes of adolescence.  And alcohol use both affects development and is affected by developmental processes. Pediatrics June 2009, VOLUME 123 / ISSUE 6 Age of Drinking Onset, Alcohol Use Disorders, Frequent Heavy Drinking, and Unintentionally Injuring Oneself and Others After Drinking Ralph W. Hingson, Wenxing Zha September 2006, VOLUME 118 / ISSUE 3 Age of Alcohol-Dependence Onset: Associations With Severity of Dependence and Seeking Treatment Ralph W. Hingson, Timothy Heeren, Michael R. Winter Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003

If you were to screen all or your chronic pain pts, pts with addiction, and many other chronic diseases, I think you would find very high ACE scores. The body under threat – full sympathetic response, pealing warning bells – those are the pathways that we need to quiet. We should not just fill opioid receptors in the brain. We are going to come back to this. I worry that I am all no opioids when I speak. I am not. I want us to recognize that 20% - 30% of your pts on chronic opioids have developed an addiciton to those drugs and let’s address that disease.

Length of Treatment Research is Unequivocal: good outcomes depend on adequate treatment length

We apply alcohol treatment to opioid treatment We apply alcohol treatment to opioid treatment. The use of 3-7 days of detox is USELESS and in fact dangerous. If you can guarantee you are sending someone to a place where they will be stablized until they get a real treatment plan, than that is useful. Abstinence for opiates works with long term treatment in highly supervised settings.

Minimum of 90 days but most people need 9 months, 15 months to really get there feet firmly on terra firma.

Go back to your diabetic. Hba1c 9-11. Fat, little exercise, poor diet Go back to your diabetic. Hba1c 9-11. Fat, little exercise, poor diet. What would it take to get that person fixed? 3-7 admission in a hospital? 6-9 months at Canyon Ranch, Plant-based diet, 2-4 hours of exercise a day, personal trainer, group therapy, can’t return home to the same kitchen and pantry. Needs complete rehab of their nutrition, activity, and may need to change jobs.

Think you drink a lot? This chart will tell you…

Massachusetts is not alone in our problems Massachusetts is not alone in our problems. I think it easy to feel as though Franklin County is the center of the opioid epidemic. It is not. There are many states that are much worse.

This is the heroin map now This is the heroin map now. Imagine Appalachia and the Entire South filled in. Imagine what our rates of Hep C and HIV will be then. Imagine what the death rate will be then. We need to be training people now to recognize and treat addiction in advance of the rug getting pulled out from under people. There is no human benefit in pulling away people’s prescriptions and having them turn to Heroin.

What actually works?

What are the costs? (OAT = Opioid Agonist Treatment)

What can be done in the #1 place where people with a substance use disorder arrive?

Study came out 3 weeks ago from my alma mater Study came out 3 weeks ago from my alma mater. 4 year span looking a screening and referral, screening and referral and a brief intervention (SBIRT), screening and referral and a brief intervention (SBIRT), ED initiated treatment with suboxone and referral to primary care for 10 week f/u. At 30 days, 37% in the initial group, 45% n the brief intervention and 78% in the buprenorphine treatment group were still engaged in addiction treatment.

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