1. Integrated Treatment for Addictions and HIV G Treisman Johns Hopkins University School of Medicine

4. Trends in lifetime prevalence of use of narcotics taken not under a doctor's orders

6. Katy M. E. Turner et al. Addiction, 106, 1978–1988

7. Probability of receiving opioid agonist therapy at study follow-up visits.Observed estimates are shown for clinic-based buprenorphinenaloxone (BUP) (circles) and referred treatment (triangles) Lucas G M et al. Ann Intern Med 2010;152:704-711 ©2010 by American College of Physicians

8. © 2011 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.2 Longer BPN leads to increased initiation and success with HAART FIGURE 3. Comparison of initiating antiretroviral therapy and viral suppression outcomes among subjects not on antiretroviral therapy at baseline: stratified analysis among subjects retained on buprenorphine/naloxone for three or more quarters. Compared to baseline, P <= 0.05 for all comparisons.

9. ASSOCIATION BETWEEN MENTAL DISORDER AND SURVIVAL TIME IN YEARS PROBABILITY OF SURVIVAL No Mental Disorder Diagnosed and at least one visit P=0.10

10. Addiction is not dependence Non-disordering dependence – Caffeine – Nicotine

11. What is addiction? Continued increasing repetitive stereotyped behavior despite mounting consequences that disrupts function in all realms of life

12. What makes a drug addictive? Tolerance – Increasing dose to achieve desired effect Dependence – Physical withdrawal when stopped Reinforcement – Provides behavioral reinforcement (behaviors that occur during drug exposure increase)

14. Reinforcing and addictive drugs Psychomotor stimulants (dopamine) Opiates Sedative-Hypnotics (GABA) Cannabinoids Phencyclidine (NMDA receptor) Hallucinogens? Nicotine and caffeine

15. Is addiction... A disease? A result of environment? A problem of the type of person involved? A conditioned behavior that becomes self sustaining?

16. The disease model Assumes a broken part in the brain Assets – Removes blame and stigma – Emphasizes medical treatment Vulnerabilities – Cannot explain data from models or recovery – Removes responsibility from patients

17. Problems with the disease approach There is a volitional component to addiction that is absent from other disease states Treatment needs to emphasize rehabilitation rather than drugs Behavioral models are better than lesion models

18. A Behavioral Model of Addictions Law of effect …probability of a behavior can be increased or decreased depending on its immediate consequence. Thorndyke 1913 Behavior environmental exposureenvironmental response positiveincrease negative decrease

19. Internal “drive” (craving) Behavior Reward-Reinforcement Satiation environmental exposureenvironmental response A Behavioral Model of Addiction

20. Can we measure reinforcement? How hard will you work to get it? What will you put up with to get it? What will you give up to get it? Which would you rather have?

22. Psychiatric comorbidity contributes to the variance

23. Experience Meaning Assumption Behavior

24. Addiction Inflammation and Cytokines Sympathetic activation and stress Day night cycle disruption HIV and HEP C Depression Decreased reward sensitivity Decreased self preservation Increase in stimulus seeking

25. Simplified model of disposition Percent of population Introversion Introversion  Punishment avoidant  Future directed  Function directed Extraversion Extraversion  Reward directed  Present directed  Feeling directed

27. Population-Disposition Introversion-Extroversion Stability- Instability

28. introversionextroversion stable unstable sanguine choleric phlegmatic melancholy

30. Why doesn’t everyone get addicted?

31. Internal “drive” (craving) Behavior Reward-Reinforcement Satiation environmental exposureenvironmental response

33. Core elements of addiction treatment Conversion Detoxification Rehabilitation – GROUP Treatment of co-morbid psychiatric conditions Relapse Prevention

34. Conversion Confrontation with a smile (motivational interviewing) Physician Goals vs. Patient Goals – Quality of Life – Longevity vs Comfort – Function Treatment Contract

35. Detoxification Stop the behavior Prevent withdrawal Diminish craving Treat potential accompanying disorders – Wernicke-Korsakoff – Endocarditis – HIV

36. Pharmacologic treatment for withdrawal Active Tapers Suppression of specific symptoms – Clonidine – Dicyclomine (Bentyl) anticholinergics – NSAID’s – Methocarbamol (Robaxin) – Antihistamines

37. Rehabilitation Damage control – Social, occupational and family intervention Environmental change – People places and things that are triggers – Structure Extinguish the habit Prescribe a new program Occupational – Vocational – Educational Social Physical Psychological

38. Adjunctive Pharmacotherapy Treatment of Psychiatric Comorbidity Substituted Addiction Blockade of reinforcement Aversive conditioning Drive suppression Symptomatic treatment for withdrawal

39. Treat Comorbid Conditions Treat mood disorders – Medication and therapy Attend to Life Story – Psychotherapy and remoralization – Mobilize social supports Manage temperament – Practical suggestions and directive advice

40. Substituted Addiction Methadone, LAAM, Buprenorphine – Addiction with Less Disorder – Decreased Reinforcement of Behavior – Other Addictions as models Nicotine Caffeine Nicotine patch, gum, and inhalers

41. Blockade of reinforcement Naltrexone – Non-addictive – Usually a dismal failure Benzodiazepine blockers

42. Aversive conditioning Disulfiram (Antabuse) Behavioral Aversive Conditioning

43. Drive suppression Bupropion for nicotine Naltrexone for alcohol – Antidepressants for cocaine? – Buprenorphine for cocaine?