1. Addiction Myths and Science David Kan, MD San Francisco, Department of Veteran Affairs

2. Overview Understand the science of addiction and its relationship to other medical diseases Understand the concepts of relapse and recovery Describe disease-specific treatment of addiction including medication assisted treatment

4. Myths of Addiction Treatment Myth of Self-Medication Treating “underlying” disorders tends not to work Depression doesn’t make you drink BUT, drugs do make you feel good (however, less and less over time)

5. Myths of Addiction Treatment Myth of Self-Medication Myth of Character Weakness Weakness or willpower have little to do with becoming addicted Educated, strong people succumb to the best drugs in the world

6. Myths of Addiction Treatment Myth of Self-Medication Myth of Character Weakness Myth of Holding One’s Liquor The “Wooden Leg” Syndrome predicts alcoholism, not immunity to alcoholism

7. Myths of Addiction Treatment Myth of Self-Medication Myth of Character Weakness Myth of Holding One’s Liquor Myth of Detoxification Getting sober is easy Staying that way is incredibly difficult Detoxification is preparatory step to further treatment

8. Myths of Addiction Treatment Myth of Self-Medication Myth of Character Weakness Myth of Holding One’s Liquor Myth of Detoxification Myth of Brain Reversibility Addiction produces permanent neurotransmitter and chemical changes “Kindling” increase risk of permanent paranoia and hallucinations (from alcohol and stimulants)

9. Facts of Addiction Treatment Addiction is a brain disease Chronic, “cancerous” disorders require multiple strategies and multiple episodes of intervention Treatment works in the long run Treatment is cost-effective

10. Common Characteristics of Addict-Criminal Offenders Unemployment Criminal justice recidivism Inability to cope with stress or anger Highly influenced by social peer group Inability to handle high-risk relapse situations

11. Common Characteristics… Emotional and psychological immaturity Difficulty relating to family Inability to sustain long-term relationships Educational and vocational deficits

12. Addiction is a Brain Disease …with biological, sociological and psychological components

13. Nature of Addiction Loss of control Harmful Consequences Continued Use Despite Consequences

14. Three “C’s” of Addiction Control Early social/recreational use Eventual loss of control Cognitive distortions (“denial”) Compulsion Drug-Seeking activities Continued use despite adverse consequences Chronicity Natural history is of multiple relapses preceding stable recovery Relapse after years of sobriety is possible

15. Compliance & Chronicity Chronic Illness Medication Compliance Relapse within 1 yr. Diabetes<60%30-50% Hypertension<40%50-70% Asthma<40%50-70% Addiction30-50% McLellan AT, Lewis DC, O’Brien CP, Kleber HD; Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000

16. Abstinence Strictly speaking, abstinence is developed, not recovered It is an abnormal condition, signifying an internal defect (disease) Addicts want to be “normal,” that is, using drugs in control

17. Self-Control Addicts seek control, not abstinence

18. Self-Control Addicts seek control, not abstinence If I can have just one, then I will be normal, just like my friends

19. What is recovered in Recovery ? Abstinence Range of Emotions Intimacy

20. Addiction Risk Factors Genetics Young Age of Onset Childhood Trauma (violent, sexual) Learning Disorders (ADD/ADHD) Mental Illness Depression Bipolar Disorder Psychosis

21. Alcohol 101 Genetics = 60% of Risk Males >> Females Available Medications Antabuse (Disulfiram):Deterrence ReVia (Naltrexone):Relapse Prevention Vivitrol (Naltrexone):Relapse Prevention Campral (Acamprosate)Relapse Prevention Effective Treatments 12-Step Cognitive-Behavioral Therapy Counseling

22. Alcohol: Rate of Metabolism = 1.0-1.5 standard drinks per hour Beer12.0 oz.5% ABV Wine05.0 oz.12.5% ABV Liquor01.5 oz40% ABV 2 nd and 3 rd DUI/DWI’s are more diagnostic than 1 st Intoxication increases risk of suicide and homicide

23. Alcohol: Cognitive Deficits Memory Disorders Impaired Abstraction Perseveration using failed problem- solving strategies Loss of Impulse Control “Alcoholic Dementia” is similar to Alzheimer’s, but shows some improvement with sobriety

24. Biological Lens Genetic predisposition 60% of alcoholism variance is predicted by genetics Animal Breeding Studies Family Tree Studies Adoption and Twin Studies High-Risk Inheritance Paradigms Neurotransmitters shifts Dopamine & Reward Pathways

25. Genetic Inheritance Human Family Tree Studies Alcoholism runs in families “Drunks beget drunkards” – Plutarch 60 A.D. Males have higher rates of alcoholism than females Females may have more depression Males show more antisocial behaviors

26. Genetic Inheritance Twin Adoption Studies Alcoholic family twin raised by non- alcoholic foster parents 4X increase in alcoholism for males 9X increase if father is antisocial Non-alcoholic family twin raised by alcoholic foster parents No increased risk

27. Cocaine 101 Freebase (crack) since 1985 No medications are effective Psychosocial treatments, including Cognitive-Behavioral Therapy and Relapse Prevention are effective Risk of permanent “kindling” of paranoia and hallucinations

28. Cocaine: Functional Imaging

29. Methamphetamine Synthetic made from ephedrine Long-Acting, up to 12+ hours Paranoia, Auditory Hallucinations “Burnt-Out Speed Freak” Persistent paranoia and hallucinations Anhedonic lack of pleasure

30. The Brain

31. Hijacking the Reward System Food Sex Excitement Comfort

32. Dopamine Spells REWARD

33. Brain Reward Pathways

34. Activation of Reward

35. Heroin 101 New production in South America High purity/potency (smokeable) Detoxification is of limited long-term efficacy Most effective treatment for chronic users is Methadone Maintenance Medications Methadone, LAAMReplacement BuprenorphineReplacement NaltrexoneOpioid Blockade

36. Death Rates in Treated and Untreated Addicts % Annual Death Rates Slide data courtesy of Frank Vocci, MD, NIDA – Reference: Grondblah, L. et al. Acta Pschiatr Scand, P. 223-227, 1990

37. Impact of MMT on IV Drug Use for 388 Male MMT Patients in 6 Programs PERCENT IV USERS 0 100 LAST ADDICTION PERIOD ADMISSION 100% 81.4% Pre- | 1st Year | 2nd Year | 3rd Year | 4th * * 63.3% 41.7% 28.9% Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

38. Crime among 491 patients before and during MMT at 6 programs Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991 Crime Days Per Year

39. Relapse to IV drug use after MMT 105 male patients who left treatment Percent IV Users Months Since Stopping Treatment Opioid Agonist Treatment of Addiction - Payte - 1998 Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

40. Twelve-Step Groups Myths Only AA can treat alcoholics Only a recovering individual can treat an addict 12-Step groups are intolerant of prescription medication Groups are more effective than individuals because of confrontation

41. Twelve-Step Groups Facts Available 7days/week, 24 hrs/day Work well with professionals Primary treatment modality is fellowship (identification) Safety and acceptance predominate over confrontation Offer a safe environment to develop intimacy

42. Therapeutic Communities Cost-effective, long-term care Effective in treating sociopathic, anti-social personalities Often very confrontational and dogmatic Risks of charismatic leadership & program corruption

43. Public Health Drug treatment is disease prevention HIV Infection reduced 6-fold in injecting drug users >90% injection drug users are infected with Hepatitis C virus

44. How Long Should Treatment Last ? Depends on patient problems/needs Less than 90 days is of limited or no effectiveness for residential / outpatient setting A minimum of 12 months is required for methadone maintenance Longer treatment is often indicated

45. Coercion Treatment does not need to be voluntary to be effective. Court-Ordered Probation Family Pressure Employer Sanctions Medical Consequences

46. “Costly” or “Cost-Effective” Expensive Incarceration: Treatment is less expensive than not treating or incarceration (1 year of methadone maintenance = $3,900 vs. $25,900 for imprisonment) 1:7 Rule: Every $1 invested in treatment = up to $7 in reduced crime-related costs Health Offset: Savings can be > 1:12 when health care costs are included Reduced interpersonal conflicts Improved workplace productivity Fewer drug-related accidents

47. Treatment Effectiveness Drug dependent people who participate in drug treatment Decrease drug use Decrease criminal activity Increase employment Improve their social and intrapersonal functioning Improve their physical health Drug use and criminal activity decrease for virtually all who enter treatment, with increasingly better results the longer they stay in treatment.

48. Medical Detoxification Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. High post-detoxification relapse rates Not a cure ! A preparatory intervention for further care

49. Medications Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Alcohol:Naltrexone, Disulfiram, Acamprosate, Odansetron Opiates:Naltrexone, Methadone, Buprenorphine Nicotine:Nicotine replacement (gum, patches, spray), bupropion Stimulants: [None to date]

50. Discussion

51. End