1. Rutgers New Jersey Medical School
Opioid Crisis in America: A Big Mistake, an Aggressive Industry, a Tricky Brain, and the 16 Milligrams that Will Bring Your Child Back to College
Petros Levounis, MD, MA
Professor and Chair
Rutgers New Jersey Medical School
Newark, New Jersey
San Antonio, Texas: August 21 to 23, 2017

2. Learning Objectives
After attending this presentation, learners will be able to:
Describe the basic model of addiction.
List three safe and effective treatments for opioid use disorder.
Discuss mindfulness in the treatment of addiction.

3. Outline
The Basic Model
The Neurobiology of Addiction
Addiction Treatments
New Directions
Conclusions

4. 1
The Basic Model

5. A Biopsychosocial Illness
Biological
Addiction
Psychological
Social
Brain Switch
Use
Olsen and Levounis, Sober Siblings, 2008. 5

6. The Root Cause of the Disaster
Porter and Jick, N Engl J Med, January 10, 1980.

7. Pharma

8. Primary non-heroin opioid admission rates (per 100,000)
Admissions: 1999
Primary non-heroin opioid admission rates (per 100,000)

9. Primary non-heroin opioid admission rates (per 100,000)
Admissions: 2001
Primary non-heroin opioid admission rates (per 100,000)

10. Primary non-heroin opioid admission rates (per 100,000)
Admissions: 2003
Primary non-heroin opioid admission rates (per 100,000)

11. Primary non-heroin opioid admission rates (per 100,000)
Admissions: 2005
Primary non-heroin opioid admission rates (per 100,000)

12. Primary non-heroin opioid admission rates (per 100,000)
Admissions: 2007
Primary non-heroin opioid admission rates (per 100,000)

13. Primary non-heroin opioid admission rates (per 100,000)
Admissions: 2009
Primary non-heroin opioid admission rates (per 100,000)

14. Marked Geographic Variation in Mortality: Estimated Age-adjusted Death Rates for Drug Poisoning by County
1999
1999
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 14

15. Marked Geographic Variation in Mortality: Estimated Age-adjusted Death Rates for Drug Poisoning by County
2002
2002
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 15

16. Marked Geographic Variation in Mortality: Estimated Age-adjusted Death Rates for Drug Poisoning by County
2005
2005
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 16

17. Marked Geographic Variation in Mortality: Estimated Age-adjusted Death Rates for Drug Poisoning by County
2008
2008
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 17

18. Marked Geographic Variation in Mortality: Estimated Age-adjusted Death Rates for Drug Poisoning by County
2011
2011
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 18

19. Marked Geographic Variation in Mortality: Estimated Age-adjusted Death Rates for Drug Poisoning by County
2014
2014
Designed by L. Rossen, B. Bastian & Y. Chong. SOURCE: CDC/NCHS, National Vital Statistics System; Tom Frieden Presentation at the Opioid Summit, Atlanta, April 2016 19

20. From Pills to Heroin
Compton, New England Journal of Medicine, 2016.

21. The Neurobiology of Addiction2
The Neurobiology of Addiction

22. DA Concentration (% Baseline)
Natural Rewards
Food
Sex
200
200
150
150
DA Concentration (% Baseline)
% of Basal DA Output
100
100
Empty 50
Box Feeding
Natural rewards stimulate dopamine neurotransmission. Eating something that you enjoy or being stimulated sexually can cause dopamine levels to increase. In these graphs, dopamine is being measured inside the brains of animals. Its increase is shown in response to food or sex cues. This basic mechanism of controlled dopamine release and reuptake has been carefully shaped and calibrated by evolution to reward normal activities critical for our survival.
Female Present 1 2 3 4 5 6 7 8 60
120
180
Sample
Number
Time (min)
Adapted from: Di Chiara et al, Neuroscience, 1999
Adapted from: Fiorino and Phillips, J Neuroscience, 1997 22

23. Effects of Drugs on Dopamine Levels
MORPHINE
COCAINE
400
% of Basal Release
100
150
200
250 1 2 3 4
5 hr
0.5
1.0
2.5 10
Dose mg/kg
300
% of Basal Release
200
100 1 2 3 4
5 hr
100
150
200
250 1 2 3
4hr
% of Basal Release
0.25
0.5
2.5
Dose (g/kg ip)
ETHANOL
NICOTINE
250
200
% of Basal Release
150
100 1 2
3 hr
Adapted from: Di Chiara and Imperato, Proceedings of the National Academy of Sciences USA, 1988; courtesy of Nora D Volkow, MD

24. Pleasure-Reward Pathways
National Institute on Drug Abuse,

25. 3
Addiction
Treatments

26. 1st Wave: Psychoanalysis26
Levounis, Journal of Medical Toxicology, 2016. 26

27. 2nd Wave: Boot Camps
DISASTER 27 27 27

28. 3rd Wave: The Current Approach
Mutual Help Groups (12-step)
Motivational Interviewing (and CBT)
Medications
Family Therapy
Primary Care Services
Mental Health Services
Aftercare
Nunes, Selzer, Levounis, Davies, Substance Dependence and Co-Occurring Psychiatric Disorders, 2010. 28

29. What Med Staff Think Patients Think
Mutual Help
What Med Staff Think Patients Think
Housing
Outpatient Tx
Medical Services
Job
Trusting People AA
Inner Peace
Community
Gov’t Services
Spirituality
God
MEDICAL STAFF
Housing
Gov’t Services
Medical Services
Outpatient Tx
Job
Community
Trusting People
Inner peace
God
Spirituality AA
PATIENTS
Inner peace
God
Medical Services AA
Housing
Spirituality
Outpatient Tx
Community
Gov’t Services
Trusting People
Job
Goldfarb, Am J Drug Alcohol Abuse, 1996.
Levounis, Zerbo, and Aggarwal, Pocket Guide to Addiction Assessment\ and Treatment, 2017.
The Neurobiology of Addiction NYU - September 15, 2014 29

30. Motivational Interviewing
Levounis, Arnaout, and Marienfeld, Motivational Interviewing for Clinical Practice, 2017.

31. Medications
-10 -9 -8 -7 -6 -5 -4 10 20 30 40 50 60 70 80 90
100
% Efficacy
Log Dose of Opioid
Full Agonist (Methadone)
Partial Agonist (Buprenorphine)
Antagonist (Naltrexone)
Renner and Levounis, Office-Based Buprenorphine Treatment of Opioid Dependence, APA Publishing, 2011.

32. 4
New Directions

33. 4th Wave: Mindfulness
“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lie our growth and our freedom.”
Viktor E. Frankl
Frankl V, Man’s Search for Meaning, 1959.
Zerbo, Schlechter, Desai, and Levounis, Becoming Mindful, 2017. 33

34. And Back to Psychodynamics…
***
Ref
% reporting any substance use disorders
*** * *
Ref
Women
Men
*p<0.05, ***p<.001 based on logistic regression analysis adjusted for race, age, educational level, personal income, employment status, relationship status, health insurance status, geographic location, MSA, age at alcohol onset, and family history of AOD problems. Reference group was “heterosexual” group.
McCabe SE, Addiction, 2009; courtesy of Sean McCabe, PhD.
Levounis, Drescher, and Barber, The LGBT Casebook, 2012.

35. 5
Conclusions

36. Addiction hijacks the pleasure/reward pathways of the brain and weakens the frontal lobes.
Mutual help, motivational interviewing, and partial agonists are the foundations of addiction treatment in 2017.

37. Thank you