Concepts in substance abuse

1

Addictions in the HIV Clinic
Glenn J. Treisman, MD, PhD ProfessorJohns
Hopkins Medical Institutions School of Medicine
From GJ Treisman, MD, PhD, at Atlanta, GA April
3, 2009, IASUSA.
International AIDS SocietyUSA
2
depression demoralization substance
abuse cognitive impairment
Mental Illness
AIDS
impulsivity depression demoralization substance
abuse cognitive impairment
3
Definition of Addiction

• One is too many but ten is not enough
• Old alcoholic adage H Kleber

4
Core concepts of addiction

• Tolerance
• Increasing dose
• Dependence
• Physical withdrawal
• Reinforcement
• Provides behavioral reinforcement

5
What is addiction?

• What drugs are addictive?
• Tolerance
• Dependence
• Reinforcement
• Continued increasing repetitive stereotyped
  behavior despite mounting consequences that
  disrupts function in all realms of life

6
Is Addiction a Disorder?

• Disordering addictions (use to abuse ratio)
• Non-disordering addictions
• Nicotine
• Caffeine
• Less disordering addictions
• Methadone lt Heroin
• Risk and Benefit

7
Reinforcing and addictive drugs

• Psychomotor stimulants (dopamine)
• Opiates
• Sedative-Hypnotics (GABA)
• Cannabinoids
• Phencyclidine (NMDA receptor)
• Hallucinogens?
• Nicotine and caffeine

8
Is substance abuse...

• A disease?
• A result of environment?
• A problem of the type of person involved?
• A conditioned behavior that becomes self
  sustaining?

9
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

10
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

11
What is behavior?
12
Behavior
Goal
Goal directed purposeful action
13
Behavior
positive
increase
environmental exposure
environmental response
Behavior
negative
decrease
14
Motivated Behavior
environmental exposure
environmental response
Behavior
Internal drive (craving)
Reward-Reinforcement
Satiation
15
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?

16
(No Transcript)
17
Treatment

• Conversion
• Detoxification
• Rehabilitation
• GROUP
• Co-morbid Treatment
• Relapse Prevention

18
Conversion

• Confrontation with a smile (group)
• Physician Goals vs. Patient Goals
• Quality of Life
• Longevity vs Comfort
• Function
• Treatment Contract

19
Detoxification

• Stop the behavior
• Prevent withdrawal
• Diminish craving
• Treat potential accompanying disorders
• Wernicke-Korsakoff
• Endocarditis
• HIV

20
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

21
Adjunctive Pharmacotherapy

• Treatment of Psychiatric Comorbidity
• Substituted Addiction
• Blockade of reinforcement
• Aversive conditioning
• Drive suppression
• Symptomatic treatment for withdrawal

22
Substituted Addiction

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

23
Blockade of reinforcement

• Naltrexone
• Non-addictive
• Usually a dismal failure
• Benzodiazepine blockers

24
Aversive conditioning

• Disulfiram
• Behavioral Aversive Conditioning

25
Drive suppression

• Bupropion for nicotine
• Naltrexone for alcohol
• Antidepressants for cocaine?
• Buprenorphine for cocaine?

26
Pharmacologic treatment for withdrawal

• Active Tapers
• Suppression of specific symptoms
• Clonidine
• Dicyclomine (Bentyl) anticholinergics
• NSAIDs
• Methocarbamol (Robaxin)
• Antihistamines

27
Treat Comorbid Conditions

• Attend to Life Story
• Psychotherapy and remoralization
• Mobilize social supports
• Treat Depression
• Medication and therapy
• Manage temperament
• Practical suggestions and directive advice

28
The Four Perspectives McHugh and Slavney

• Disease
• Temperament
• Behavior
• Life Story

29
Depression

• Mood
• Vital Sense
• Self attitude
• Anhedonia

30

• It is much more important to know what sort of
  patient has a disease than what sort of disease a
  patient has.
• William Osler

31
Simplified model of disposition
percent of population
Introversion
Extroversion
32

• Population-Disposition

Stability- Instability
Introversion-Extroversion
33
stable
sanguine
phlegmatic
introversion
extroversion
choleric
melancholy
unstable
34
Problems of life story

• An assumptive world
• Assumptions provoke experience
• Experience shapes assumptions
• We understand these experiences using meaning
• Provides the software operating system for data
  and action
• Can be rescripted or rewritten

35
Experience
Meaning
Behavior
Assumption
36
Education Treatment Plan Induction Medication
Adjustment
Poor Compliance
Assessment of Comorbid Disorders
Engagement of more aggressive therapy
Better Compliance Improved Self Efficacy
Treat Comorbid Disorders Collaborative Treatment
Better Outcome
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)