S' Alex Stalcup, M'D'

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S. Alex Stalcup, M.D.

• New Leaf Treatment Center
• 251 Lafayette Circle, Suite 150
• Lafayette, CA 94549
• Tel [phone]
• Fax [phone]
• alex_at_nltc.com www.nltc.com

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Addiction is a Pediatric Disease

• 80 of addicts have risk factors known in
  childhood
• Family history of addiction
• ADHD (attention deficit hyperactivity disorder)
• Mood disorder (depression, anxiety, trauma)
• School failure
• 80 of adult drinkers try alcohol before age 18.
• Of children who begin drinking before age 14, 47
  will become alcoholics.
• Average age of initiation to marijuana use is age
  15.

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What is a Drug?

• A drug is a pleasure producing chemical. Drugs
  activate or imitate chemical pathways in the
  brain associated with feelings of well-being,
  pleasure and euphoria.

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Neuroadaptation, Tolerance, and Withdrawal

• Neuroadaptation is the brains response to over
  stimulation from drugs. Drug-specific circuits
  cause a mixture of sedation and stimulation or
  intoxication.
• Tolerance is the process by which the reward and
  pleasure centers of the brain adapt to high
  concentrations of pleasure neurotransmitters. In
  direct response to overstimulation, the brain
  regions decrease in sensitivity and become
  unresponsive (deaf) to normal levels of
  stimulation.
• In addition to pleasure circuits each drug type
  affects other specific circuits. Other brain
  pathways overstimulated by drugs also neuroadapt
  and become under active, directly leading to
  anxiety, depression, and loss of energy.
• Once neuroadaptation develops (tolerance), there
  will always be withdrawal symptoms that are the
  mirror image of the drug effects. Cessation of
  drug use leads to inversion of the high
  sobriety becomes pleasureless, anxious,
  sleepless, and lacking energy
• Under unstimulated conditions (without drugs)
  there is profound interference with the ability
  to experience normal pleasure. When sober, the
  user feels anhedonia, anxiety, anger, frustration
  and craving. The pleasure system remains impaired
  for months to years, interfering with sobriety,
  learning, and impulse inhibition.

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Definition of Addiction

• Compulsion loss of control
• The user cant not do it s/he is compelled to
  use.
• Compulsion is not rational and is not planned.
• Continued use despite adverse consequences
• An addict is a person who uses even though s/he
  knows it is causing problems.
• Addiction is staged based on adverse
  consequences.
• Craving daily symptom of the disease
• The user experiences intense psychological
  preoccupation with getting and using the drug.
• Craving is dysphoric, agitating and it feels
  very bad.
• Denial/hypofrontality distortion of cognition
  caused by craving
• Under the pressure of intense craving, the user
  is temporarily blinded to the risks and
  consequences of using.

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Abuse versus Addiction

• Substance Abuse is distinguished from Addiction
  by the appearance of tolerance and withdrawal,
  leading to loss of control over use.
• Substance abusers require motivation to stop.
• Addicts require treatment to stop.

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Entrance into System
Arrest
Psych Emergency
Emergency Room
Assessment
Domestic Violence
Family Court
Probation - Parole
Schools
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Monitoring and Treatment
In-custody Treatment
Residential Treatment
IOP Sober Living
Intensive Outpatient IOP
Addict
Re-entry Monitoring Random UDS 6 months
(Positive UDS)
Entry
Assessment
Monitoring Random UDS 6 tests/90 days
?
Discharge
Unsure
Discharge
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National Survey on Drug Use and Health Statistics
2007
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Prescription Drug Abuse

• Opiate pain medications
• Benzodiazepine tranquilizers
• Prescription stimulants
• (Adderall, Ritalin)
• Sleeping pills, muscle relaxants

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Sentinel Events in Prescription Drug Abuse

• Overdoses in younger individuals
• DUI arrests with low BAL
• Youth falling asleep in school
• Youth stealing from parents and friends
• Increased schoolyard drug and pill sales

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National Survey on Drug Use and Health Statistics
2007
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National Survey on Drug Use and Health Statistics
2007
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Youve Got Drugs V Prescription Drug Pushers on
the Internet. National Center on Addiction and
Substance Abuse, Columbia University 2008
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Prescription Opiates

• Generic Brand Name Non Tolerant 24 hr. dose
• Codeine w/acetaminophen 500 mg
• HydrocodoneVicodin, Lortab, Norco 20mg-60 mg
• Hydromorphone Dilaudid 20 mg-60 mg
• Oxycodone Percodan, OxyContin 20 mg-60 mg
• Morphine sulfate MS Contin 30 mg-60 mg
• Fentanyl Duragesic (transdermal), Actiq 25
  mcg-50 mcg
• Tolerant Users only Tolerant 24 hr. dose
• Morphine sulfate MS Contin 60 mg-upward
• Fentanyl Duragesic (transdermal) 75 mcg-300 mcg
• Methadone Methadose 60 mg-300 mg
• Buprenorphine Suboxone, Subutex 6 mg-32 mg

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Opiate progression from pills to the needle

• Historically, untreated dependence on
  prescription opiates led to a trajectory from
• Pills ingested orally
• Pills crushed and snorted or smoked
• Heroin snorted or smoked
• Heroin used intravenously

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A 33-year follow-up of narcotics addicts

• .

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Overview of Buprenorphine Suboxone and Subutex

• Highly safe medication (acute chronic dosing).
• Primary side effects like other mu agonist
  opioids (e.g.,nausea, constipation) but may be
  less severe.
• No evidence of significant disruption in
  cognitive or psychomotor performance with
  buprenorphine maintenance.
• No evidence of organ damage with chronic dosing.
• Use of Buprenorphine in the Pharmacologic
  Management of Opioid Dependence A Curriculum of
  Physicians. (eds Strain EC, Trhumble JG, Jara
  GB) CSAT. 2001

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Prescription Tranquillizers

• Dose Equivalent To Alcohol
• (2oz liquor or 2 glasses of wine or 2 cans of
  beer)
• Alprazolam (Xanax) 0.5- 1mg
• Diazepam (Valium) 10mg
• Chlordiazepoxide (Librium) 25mg
• Clonazepam (Klonopin) 1-2mg
• Lorazepam (Ativan) 2mg
• Temazepam (Restoril) 30mg
• Butalbital (in Fiorinal) 100mg
• Carisoprodol (Soma ) 350mg
• Zolpidem (Ambien) 10 mg

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Sedative-Hypnotic Effects

• Effects
• Calm Euphoria
• Release of Inhibitions
• Sleep Inducing
• Sedation/Sleepiness
• Slurred Speech
• Unsteady gait (Ataxia)
• Confusion
• Forgetfulness
• Slows heart rate
• Decreases blood pressure
• Symptom may continue for months

• Withdrawal
• Dysphoria
• Anxiety
• Insomnia
• Sweating (Diaphoresis)
• Tremor
• Tachycardia
• Hypertension
• Hyperventilation
• Elevated temperature
• Hallucinations
• Seizures
• Delirium tremens

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Prescription Stimulants

• Adderall is a brand-name pharmaceutical
  psychostimulant composed of mixed amphetamine
  salts. Adderall is widely reported to increase
  alertness, concentration and overall cognitive
  performance while decreasing user fatigue.
• Prescription Stimulants are Schedule II drugs
  under the Controlled Substance Act for the United
  States.
• Concerta, Vyvanse, Dexedrine are similar, often
  abused, prescription psycho-stimulants.

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Medications for Stimulant Dependence

• Antidepressants (anhedonia/anergia)
• Effexor XR 150-300 mg
• Cymbalta 60 mg
• Wellbutrin XL 150-300 mg
• Desipramine 100-200 mg
• Anti-Craving Medications
• Modafinil 100-200 mg
• Methylphenidate LA 10-40 mg
• Buproprion 150-300 mg
• Concerta 18-54 mg
• Dexedrine SR 20-30 mg

• Disorders of Sleep
• Trazedone 50-300 mg
• Seroquel 25-100 mg
• Imipramine 100-200 mg
• Disorders of Thought
• Abilify 2-10 mg
• Haldol 1-2 mg Risperdal 1-3 mg

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Are you at Risk?

• B P S M
• The Bio-Psycho-Social Model
• E W M S
• Environment
• Withdrawal
• Mental Health
• Stress

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Bio-Psycho-Social Model

• Predisposition
• Genetics
• Childhood Sexual Abuse
• Mental Illness
• Acquired Hypofrontality
• in utero alcohol/drug exposure low birth
  weight
• perinatal asphyxia head injury
• The Drug / Circumstances of First Use
• Enabling System

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C I M Model Treatment Causes of Craving

• E W M S
• Environmental cues (Triggers)
• immediate, catastrophic, overwhelming craving
  stimulated by people, places, things associated
  with prior drug-use experiences
• Drug Withdrawal
• inadequately treated or untreated
• Mental illness symptoms
• inadequately treated or untreated
• Stress equals craving

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Environmental Cueing Conditioned Craving

• Drug pleasure becomes associated with specific
  people, places, and things to encounter any of
  those things in the environment is to trigger
  craving for the drug. Such triggers persist for
  decades after use.

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Bio-Psycho-Social Model Are you at Risk?

• Apply B P S M (bio-psycho-social model) to
  yourself
• Family history of addiction?
• Do you have a tendency to boredom or ADHD?
• Are you anxious or depressed?
• Have you suffered sexual trauma?
• Do you use substances to reduce stress?
• Did drug and alcohol use enter your life at a
  difficult time?
• Are you surrounded by drug and alcohol users?

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Bio-Psycho-Social Model Are you in trouble?

• How can you tell if you are getting into trouble?
• Are you using more frequently and using greater
  amounts?
• Have you developed tolerance?
• Is your use causing adverse consequences grades,
  friends, money, health, unwanted sexual behavior?
• Do you crave the drug under addiction conditions
  Environment, Withdrawal, Mental Health, Stress
  (EWMS)
• If so, when you crave the drug, can you talk
  yourself into using it, even when you have
  resolved to not use?
• When you have resolved not to use, under known
  craving conditions, do you find yourself using
  environmental cues, anxiety or blue, withdrawal
  (bored, irritable, sleep), or when you are
  stressed?

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Bio-Psycho-Social Model Are You an Addict?

• TRY THE EXPERIMENT
• Resolve not to use for 5 weeks.
• Go about your usual daily activities.
• Put yourself around the drug and people using it.

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Bio-Psycho-Social Model Are You an Addict?

• AFTER 5 WEEKS
• Were you able to not use?
• Did you find your mind talking you into using?
• Did you struggle not to use?
• Were you able to have pleasure without using?
• Did you have problems with boredom, depression or
  anxiety?

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Bio-Psycho-Social Model What to do

• Get out of the using environment.
• Find alternative sources of pleasure.
• Work on balancing stress.
• Seek help for mental health issues and other
  personal stresses.

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Addiction Risk Resilience

• Inherited predisposition (genetics)
• Childhood trauma or abuse
• Unwanted sexual involvement before age 13
• Mental Illness depression, anxiety, personality
  disorder
• Attention Deficit Disorder (ADD)
• Learning disabilities/school failure
• Subjected to teasing, bullying
• Acne and/or obesity
• Other than heterosexual orientation
• Social rejection
• Early sexual involvement
• Onset of drug use before age 16
• Enabling environment
• Ignorance

• No family history of addiction
• Good mental health
• Academic competence
• Positive relationship with an adult
• Family eats dinner together 5 days/wk
• Peer group participation (clubs)
• Participation in sports
• Participation in music, drama or dance
• Involvement in faith-based activities
• Taking care of pets
• Volunteer activities
• Social acceptance
• Environment disapproves of drug use
• Immediate, appropriate scaled consequences for
  alcohol/drug use.
• Early intervention for alcohol/drug use

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REFERENCES

• --- Responsibility and choice in addiction.
  Psychiatric Services. 53(6)707-13 (2002).
• Bechara A. Decision making, impulse control and
  loss of willpower to resit drugs a
  neurocognitive perspective. Nature Neuroscience.
  81458-63 (2005)
• Dackis C, OBrien C. Neurobiology of addiction
  treatment and public policy ramifications. Nature
  Neuroscience. 8(11)1431-6 (2005).
• Nestler EJ, Malenka RC. The addicted brain.
  Scientific American.com February 9, 2004.
• Stalcup SA, Christian D, Stalcup JA, Brown M
  Galloway GP. A treatment model for craving
  identification and management. Journal of
  Psychoactive Drugs. 38235-44, 2006
• Volkow ND, Fowler JS, Wang GJ. The addicted human
  brain insights from imaging studies. The Journal
  of Clinical Investigation. 111(101444-51 (2003).
• Weinberger DR, Elvevag B, Giedd JN. The
  adolescent brain a work in progress. National
  Campaign to Prevent Teen Pregnancy. June 2005.