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A New Paradigm for Recovery University of Florida Scott Teitelbaum, M.D. FASAM, FAAP, Vice Chairman & Chief of Addiction Medicine * – PowerPoint PPT presentation

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Title: Statistics


1

A New Paradigm for Recovery University of
Florida Scott Teitelbaum, M.D. FASAM, FAAP, Vice
Chairman Chief of Addiction Medicine
2
ASAM Definition of Addiction
  • Addiction is a primary, chronic disease of brain
    reward, motivation, memory and related circuitry.
    Dysfunction in these circuits leads to
    characteristic biological, psychological, social
    and spiritual manifestations. This is reflected
    in an individual pathologically pursuing reward
    and/or relief by substance use and other
    behaviors.
  • Addiction is characterized by inability to
    consistently abstain, impairment in behavioral
    control, craving, diminished recognition of
    significant problems with ones behaviors and
    interpersonal relationships, and a dysfunctional
    emotional response. Like other chronic diseases,
    addiction often involves cycles of relapse and
    remission. Without treatment or engagement in
    recovery activities, addiction is progressive and
    can result in disability or premature death.

3
Addiction is a Developmental Disease

1.8
TOBACCO
THC
1.6
ALCOHOL
1.4
1.2
1.0
in each age to develop first-time dependence
0.8
0.6
0.4
0.2
0.0
70
75
5
10
15
20
25
30
35
40
45
50
55
60
65
Age
Age at tobacco, at alcohol and at cannabis
dependence, as per DSM IV
National Epidemiologic Survey on Alcohol and
Related Conditions, 2003
4
Gateway Drug
5
Statistics
  • Those aged 18-25 most likely to use illicit
    drugs.
  • Age at which an adolescent begins to use alcohol
    is a predictor of later alcohol and drug
    problems, particularly if first use is before age
    15.
  • 60 of persons aged 18-25 have tried an illicit
    drug before
  • 34 have tried an illicit drug in the past year
  • 20 have tried an illicit drug in the past month
  • National Household Survey on Drug Abuse, 2005

6
(No Transcript)
7
Winter, 2013 SAMHSA
  • Between 2010 2011, non-medical use of
    prescription drugs declined among young adults
    ages 18-25 (from 2M to 1.7M 14)
  • Success of national efforts to address
    prescription drug problem
  • BUT marijuana and heroin use increased

8
Access predicting introduction to use
  • As to obtaining prescription opiates, gt50 of
    12th graders were given the drugs or bought them
    from a friend or relative
  • Despite age groups internet facility, number
    purchasing opioids on internet was negligible

9
Inherent trust of prescribed drugs
  • Less harmful because medically administered
  • Dosage regulated by medical profession and
    governmental oversight
  • Purity of substance and quality control

10
Might Not Meet Todays FDA Standards
11
  • Young adults commonly transitioning from
    prescription opioids to heroin
  • Availability of heroin scarcity of Rx opiates
  • Price of heroin
  • 2010 to 2011, heroin overdose deaths increased
    47 in one year (2,789 to 4,102) across entire
    age spectrum of U.S. population

12
National Institute on Alcohol Abuse and Alcoholism
  • 36 of those aged 19-28 report having consumed
    more than 5 drinks in a row in the preceding 2
    weeks
  • Hippocampal volumes were found to be
    significantly smaller in those youths with an
    Alcohol Use Disorder
  • Smaller hippocampal volumes with longer-duration
    AUD
  • May effect brain structures critical to learning
    and memory formation

13
Generation Rx
  • 18 of teens have abused Vicodin
  • 20 tried Ritalin or Adderall without Rx
  • 9 abused OTC cough syrup to get high
  • More teens had abused a prescription painkiller
    in 2004 than Ecstasy, cocaine, crack or LSD
  • April 21, 2005. Partnership for a Drug Free
    America. 17th annual study of teen drug abuse.

14
Designer DrugsWhats New Ongoing
G
Speed
E
Ecstasy

BZP
Special K
Crystal
Pot
DMT
15
Its All About Sensation
Serotonin rush
  • Smell sensation is intensified by the high,
    resulting in a pleasurable effect from the fumes
  • Vicks inhalants, cough drops, surgical masks with
    med rub

16
Neurotoxicity of Drugs
substantia nigra
locus ceruleus
Whats happening at the cellular level?
17
Designer Cannabinoids
  • This raising suspicion that these products may
    contain unknown chemicals that produce effects
    similar to cannabinoids
  • In Dec. 2008 a synthetic cannabinoid JWH-018 was
    discovered in the herbal smoking blend Spice
  • Other synthetic cannabinoids HU-210, HU-211, and
    JWH-073 were also discovered and are likely
    responsible for the psychoactive effects in these
    products

18
Designer Cannabinoids
  • Synthetic cannabinoids can produce the same or
    even more powerful effects as those produced by
    the cannabinoid molecules in the marijuana plant
  • They also have very different molecular
    structures than the plant cannabinoids

19
Nov. 4, 2002
20
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21
Marijuana Perceived Risk vs. Use
22
Adolescents with AUD still appeared to have
reduced neuropsychological functioning after 3
weeks of abstinence
23
Arrested Development
  • Normal risk-taking behaviors magnified with the
    addition of a substance
  • Pre-frontal cortex (responsible for logical
    thought, judgment, decision making) not fully
    formed until mid- 20s. Substance use can impair
    healthy brain development
  • Emotional coping skills often delayed as a result
    of substance use

24
ADDICTION IS A DISEASE OF THE BRAIN Like other
diseases, it affects tissue function
Decreased Heart Metabolism in Heart Disease
Patient
Healthy Heart
Sources From the laboratories of Drs. N. Volkow
and H. Schelbert
25
Hypofrontality in Cocaine Dependent Patients
Reduced Metabolic activity at baseline in cocaine
dependent subjects
26
Drugs Attack the Prefrontal Cortex Dependence
Consequences are related to dysfunctions in the
Prefrontal Cortex
  • Unfortunately the Prefrontal Cortex is Critical
    for
  • Decision-making
  • Weighing of risks vs. rewards
  • Assigning emotional valence to stimuli
  • Suppressing limbic impulses
  • Goal-directed behaviors

27
The Memory of Drugs
Amygdalanot lit up
Amygdalaactivated
Front of Brain
Back of Brain
Nature Video
Cocaine Video
28
The Adolescent Brain is Still Developing
Amygdalo-cortical Sprouting Continues Into Early
Adulthood
Childhood
Adolescence
Adult
During Adolescence the COGNITION-EMOTION
Connection is Still Forming
Brain areas where volumes are smaller in
adolescents than young adults
Sowell, E.R. et al., Nature Neuroscience, 2(10),
pp. 859-861, 1999.
Cunningham, M. et al., J Comp Neurol 453, pp.
116-130, 2002.
29
Brain Mapping
Talking
Female
Nagging Area
Wine Drinking
Shopping
More Shopping
Feelings Central
Affinity for Shiny Objects
Sex Particle
Grudge Holding and Recounting Center
Courtesy of Paul Earley / TRC
30
Brain Mapping
Male
Blank Stare
Beer Drinking
Belching and Gas Expulsion
Sex
More Sex
Video Games
Crotch Scratch
Commitment Particle
TV Remote Control Coordination Center
Courtesy of Paul Earley / TRC
31
Adolescent Brain
  • These brain changes are relevant to adolescent
    behavior
  • Prefrontal cortex (PFC) is pruned and not fully
    developed until mid-20s
  • Amygdala (and n.a.) show less pruning and tend to
    dominate the PFC

32
Adolescent Brain Changes
prefrontal cortex
  • These brain changes are relevant to adolescent
    behavior
  • Prefrontal cortex (PFC) is pruned not fully
    developed until mid-20s
  • Amygdala (and n.a.) show less pruning and tend to
    dominate the PFC

amygdala
nucleus accumbens
judgment
reward system
Ken Winters, Ph.D.
33
Judgment vs. Reward
Prefrontal Cortex Judgment
Amygdala Reward System
Nucleus Accumbens
Ken Winters, Ph.D.
34
Adolescent Brain
  • This imbalance leads to... ? planned thinking
    ? impulsiveness ? self-control ? risk-taking

Drugs are bad!
I like to use drugs!
PFC
amygdala
Ken Winters, Ph.D.
35
  • From Oops to Dependence

Ken Winters, Ph.D.
36
Oops Phenomenon
  • First use to FEEL GOOD
  • Some continue to compulsively use because of the
    reinforcing effects (e.g., to FEEL NORMAL)
  • Changes occur in the reward system that promote
    continued use

Ken Winters, Ph.D.
37
Reward System
  • The reward system is responsible for seeking
    natural rewards that have survival value
  • seeking food, water, sex, and nurturing
  • Dopamine is this systems primary neurotransmitter

Ken Winters, Ph.D.
38
Addiction Liability
  • 10 who ever use marijuana become daily users
  • Conditional dependence risk of dependence of
    those who ever use substance
  • Marijuana 9
  • Ethanol 15
  • Cocaine 17
  • Heroin 23
  • Tobacco 32

39
Age of Onset of First Alcoholic Symptoms Among
Alcoholics
Age (years)
10 14 3
15 19 39
20 24 22
25 30 15
30 34 5
35 40 4
40
Natural History of Primary Alcoholism
Years
Age at first drink 12-14
Age at first intoxication 14-18
Age at first minor problem 18-25
Usual age of onset 23-33
Usual age of treatment entry 40
Usual age of death 55-60
Leading cause Heart or liver disease, Cancer,
Accidents, Suicide
41
Socio-cultural
Biological
The processes that initiate and maintain
alcoholism are regulated by interactions among
nerve cells in the brain.
Influences susceptibility to drug usage
Psychological
Environmental
42
NIH/NIDA
43
Cannabis Abuse and the Adolescent Brain
44
Epidemiology
  • Marijuana is the most widely used illicit drug
    both in the U.S. world-wide
  • More than 75 million (over 34) of Americans 12
    years or older have tried it at least once
    almost 19 million have used it in the past year
  • Average age of 1st use has been declining
  • 12-17 year olds 13.6 years
  • 18-25 year olds 16 years
  • While most discontinue marijuana by their
    mid-20s, a subset maintain daily, long-term use

45
Marijuana- Potency D.E.A. Seizure Data
46
Marijuana- Withdrawal
  • Proposed Syndrome for DSM-V
  • Common Sx
  • Anger or aggression
  • Decreased appetite or weight loss
  • Irritability
  • Nervousness/anxiety
  • Restlessness
  • Sleep difficulties, including strange dreams
  • Equivocal Sx
  • Chills
  • Depressed Mood
  • Stomach Pain
  • Shakiness
  • Sweating
  • Relatively mild not recognized in DSM-IV
  • Precipitated by cannabanoid antagonist
  • Duration 1-30 days

47
Marijuana- Chronic Effects
  • Behavioral- Amotivational syndrome
  • Cognitive- impaired memory/attention
  • Psychiatric- rare but real permanent psychosis
    (likely flips those predisposed)
  • Respiratory- cancer, COPD
  • Cardiovascular- HTN, tachycardia, MI
  • Decreased Immunity
  • Teratogenicity- unknown extent of fetal
    neurotoxicity
  • Reproductive- decreased testosterone, sperm
    count/motility inhibits prolactin, LH, GH

48
Medical Utility of Marijuana
  • Some efficacy shown in many areas
  • However no studies are available comparing
    marijuana to best known available treatments
  • Also, smoking as a delivery mode is undesirable
    because of toxicity and variability in dosing

49
CANNABIS AND THE BRAIN
  • Increased risk of schizophrenia
  • Reduced Thalamus size
  • Decreased IQ
  • Decreased efficiency of executive function
  • Hyperactive reward centers

50
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51
Relation Between Marijuana other Drug Use
  • Early age of onset is a major predictor both of
    continued frequent marijuana use of likelihood
    of using other drugs (Denenhardt, et al. 2001,
    Lynsky, et al. 2003)
  • The increased potency of marijuana may make the
    brain less responsive to endogenous cannabinoids.
    This may be especially marked in the still
    developing adolescent brain
  • Combination of earlier onset stronger marijuana
    may increase anxiety apathy in teens make
    other drug use more attractive
  • Twin studies found early marijuana users had
    increased rates of other drug use and problems
    later on odds of other drug use ranged from
    2.1-5.2 times higher

52
Cannabis most prevalent illicit drug identified
in impaired drivers
  • Risk of involvement in a motor vehicle accident
    (MVA) increases 2-fold after cannabis smoking.
  • Cannabis smoking increases lane weaving and
    impaired cognitive function.
  • Critical-tracking tests, reaction times,
    divided-attention tasks, and lane position
    variability all show cannabis-induced impairment.
  • Combining cannabis with alcohol enhances
    impairment, especially lane weaving.

Hartman RL, Huestis MA. Cannabis Effects on
Driving Skills. 2013 59(3) 478-492.
53
Marijuana Use Linked with Increased Risk of Motor
Vehicle Crashes
  • Greater the amount of marijuana in a persons
    urine, the greater the risk of a car crash
  • 28 of drivers who died in an accident tested
    positive for non-alcohol drugs (most commonly,
    marijuana)
  • Marijuana use by drivers is associated with a
    significantly increased risk of being in a motor
    vehicle crash.

Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong
KY, Li G. Marijuana Use and Motor Vehicle
Crashes. Epidemiologic Reviews. Advance Access
published October 4, 2011.
54
USER PROFILE
  • Users typically start in late teens
  • Use peaks in 20s
  • Use dramatically declines with association of
    starting families and careers
  • 10 will become daily users
  • 20-30 will become weekly users

55
Treatment of Young Adults
  • Challenges
  • YA score higher on pre-contemplation, lower on
    contemplation, determination, action, motivation
    and readiness for change than older adults
  • Higher rates of treatment non-compliance and
    positive drug-test at discharge
  • American Journal of Drug and Alcohol Abuse, 2003

56
Approaches to Treatment of the Young Adult
  • Focus on the treatment readiness
  • Work on development of healthier coping skills
  • Work on improving interpersonal relationships
  • Treatment of underlying psychiatric conditions
    (common in early use of substances)
  • Family therapy essential to challenge familial
    patterns and educate loved ones

57
Relapse Rates Are Similar for Drug Dependence And
Other Chronic Illnesses
Addiction Treatment Does Work
100
90
80
70
60
Percent of Patients Who Relapse
50
40
30
20
10
0
Drug Dependence
Type I Diabetes
Hypertension
Asthma
Source McLellan, A.T. et al., JAMA, Vol 284(13),
October 4, 2000.
58
Treatment Today
  • Only 1 in 10 Americans who need treatment receive
    it
  • Of those that need it, approximately 95 dont
    think they do
  • Of the 5 who believe they need it, 2/3 made no
    effort to obtain it
  • Less than 50 of those admitted to publically
    funded treatment successfully completed treatment

59
Acute Care Treatment as a Revolving Door
  • Of those admitted to the U.S. public treatment
    system in 2003, 64 were re-entering treatment
    including 23 accessing treatment the second
    time, 22 for the third or fourth time, and 19
    for the fifth or more time (OAS/SAMHSA, 2005).

60
The Prevailing Acute Care Model
  • An encapsulated set of specialized service
    activities (assess, admit, treat, discharge,
    terminate the service relationship).
  • A professional expert drives the process.
  • Services transpire over a short (and
    ever-shorter) period of time.
  • Individual/family/community is given impression
    at discharge (graduation) that recovery is now
    self-sustainable without ongoing professional
    assistance (White McLellan McLellan, in press).

61
Treatment (Acute Care Model) Works!
  • Post-Tx remissions one one-third, AOD use
    decreases by 87 following Tx, , substance
    substance-related problems decrease by 60
    following Tx (Miller, et al, 2001).
  • Lives of individuals and families transformed by
    addiction treatment.

62
Treatment Works, BUT
  • POST-TREATMENT RELAPSE
  • The majority of people completing addiction
    treatment resume AOD use in the year following
    treatment (Wilbourne Miller, 2002).
  • Of those who consume alcohol and other drugs
    following discharge from addiction treatment, 80
    do so within 90 days of discharge (Hubbard,
    Flynn, Craddock, Fletcher, 2001).

63
Treatment Works, BUT
  • LOW ATTRACTION
  • Only 10 of those needing treatment received it
    in 2002 (SAMHSA, 2003) access compromised by
    waiting lists (Donovan, et al, 2001).
  • HIGH ATTRITION
  • More than half of clients admitted to addiction
    treatment do not successfully complete treatment

64
Treatment Works, BUT
  • LOW SERVICE DOSE
  • Inadequate doses of Tx contribute to risk of
    relapse future readmissions
  • LACK OF CONTINUING CARE
  • Only 1 in 5 adult clients participated in
    continuing care (McKay, 2001) and only 36 of
    adolescents received any continuing care
    (Godley, Godley Dennis, 2001)

65
Fragility of Early Recovery
  • Most individuals leaving addiction treatment are
    fragilely balanced between recovery and
    re-addiction in the hours, days, weeks, months,
    and years following discharge.
  • Recovery and re-addiction decisions are being
    made at a time that service professionals have
    disengaged from their lives, while many sources
    of recovery sabotage are present.

66
Similarities to Other Medical Disorders
  • Substance addiction comparable to asthma,
    hypertension and diabetes.
  • Risk of relapse highest during first 3-6 months.
  • Length of time in treatment is key
  • Patients respond best to a combination of self
    help and behavioral interventions.
  • Treatment of severe cases dual disorders
    requires experts but, improves outcomes

67
Phase I What are Physician Health Programs (PHP)?
  • Not treatment, disciplinary, law enforcement or
    licensing organizations
  • Active care managers overseeing long-term care
    including drug testing
  • They select and communicate with caregivers
    including treatment programs, monitoring
    organizations and doctors/therapists/counselors
  • Physicians who enter PHP care face serious
    consequences for any noncompliance including any
    alcohol or drug use

68
PHP Long-Term Drug Test Results
  • Over the course of 5 years
  • 78 of all physicians had zero positive drug
    tests
  • 14 had only 1 positive drug test
  • 3 had only 2 positive drug tests
  • 5 had 3 or more

69
Lessons from the PHPS
  1. Zero tolerance for any use of alcohol and other
    drugs
  2. Thorough evaluation and patient-focused (rather
    than program-focused) care
  3. Prolonged, frequent random testing for both
    alcohol and other drugs
  4. Effective use of leverage
  5. Defining and managing relapses swift, certain
    and meaningful consequences for any substance use
    and noncompliance
  6. Goal of lifelong recovery rooted in the 12-Step
    fellowships

70
The New HIGHER Standard
  • The new paradigm has been successfully used in
    the criminal justice system a population
    entirely different than physicians

71
New Paradigm in the CJS
  • Hawaiis Opportunity Probation with Enforcement
    (HOPE) and South Dakotas 24/7 Sobriety Project
  • These programs uphold the zero tolerance standard
    through drug tests and immediate, brief,
    incarceration for any drug use
  • Treatment is available on offender request but
    only required for individuals who demonstrate the
    need, using Behavioral Triage
  • 12-Step participation is optional but encouraged

72
HOPE Drug Test Results
  • Over the course of one year
  • 61 of all HOPE participants never had a single
    positive drug test
  • 20 had only 1
  • 9 had 2
  • 10 had 3

(Hawken Kleiman, 2009)
73
24/7 Sobriety Drug Test Results
  • Over the average 111 days of participation
  • 55 never fail a test
  • 17 fail only 1 time
  • 12 fail only 2 times
  • 16 fail three 3 times

74
Summary of Findings
  • Zero tolerance with swift, certain, and
    meaningful consequences for any use of alcohol
    and other drugs contrary to reasonable
    assumptions leads to lower rates of use, higher
    rates of long-term success, and lower rates of
    failure
  • PHPs produced impressive results previously
    unseen
  • HOPE and 24/7 Sobriety programs produced lower
    rates of new crimes and lower rates of
    incarceration
  • Use of new concept of Behavioral Triage
    treatment is reserved for those who need it to
    stay clean and sober and for those who choose it

75
How Are These Programs Different?
  • Old Paradigm of care management
  • Infrequent or no testing when testing occurs in
    treatment, it is scheduled
  • Responses are long-delayed and unpredictable to
    missed visits, missed tests, and positive tests
  • Virtually all treatment is short-term (30 days, a
    few months, or maybe a year) while the substance
    use disorders last for lifetimes
  • The 12-Step programs are underused or not used at
    all in many current treatment programs

76
Effective substance treatment
  • Typically incorporates many components, each
    directed at a particular aspect of the illness
  • Must help the individual stop using drugs,
    maintain a drug-free lifestyle, and achieve
    productive functioning in the family, at work,
    and in society
  • Need NOT be voluntary to be effective!

77
Wisdom of involuntary treatment order
  • 21 of Americans ages 18-25 have substance use
    disorder to severity requiring treatment
  • 96 of these addicted individuals do not perceive
    the need for assistance
  • Courts provide critical access to care

78
What is recovery? A working definition from the
Betty Ford Institute
  • The Betty Ford Institute Consensus Panel
  • Journal of Substance Abuse Treatment 2007 33
    221-228.
  • There is an unknown but very large number of
    individuals who have experienced and successfully
    resolved dependence on alcohol or other drugs.
    These individuals refer to their new sober and
    productive lifestyle as recovery. Although
    widely used, the lack of a standard definition
    for this term has hindered public understanding
    and research on the topic that might foster more
    and better recovery-oriented interventions.
  • To this end, a group of interested researchers,
    treatment providers, recovery advocates, and
    policymakers was convened by the Betty Ford
    Institute to develop an initial definition of
    recovery as a starting point for better
    communication, research, and public
    understanding.
  • Recovery is defined in this article as a
    voluntarily maintained lifestyle composed
    characterized by sobriety, personal health, and
    citizenship. This article presents the
    operational definitions, rationales, and research
    implications for each of the three elements of
    this definition.

79
The Betty Ford Institute Consensus Pane (Dr
Gold was a member of this panel )Journal of
Substance Abuse Treatment , 2007 33221-228.
  • Recovery a voluntarily maintained lifestyle
    characterized by
  • Sobriety
  • Early (1-11 months)
  • Sustained (1-5 years)
  • Stable (gt 5 years)
  • Personal health
  • Physical
  • Mental
  • Social
  • Spiritual
  • Citizenship
  • Giving-back
  • Quality of life

80
  • While science has taught us that addiction is a
    hijacking of the brain, recovery must involve
    healing of the heart and the soul.

81
Recovery
Drug Use
Addiction
Treatment
Normal
82
The Great ChallengeFor Addiction Treatment in
21st Century
  • To Integrate
  • Addiction Medicine, Psychiatry and Spirituality
    in the Treatment of Substance Use Disorders.

83
Challenges
  • Increasing Rx misuse
  • Younger age of onset of use
  • More MJ smoking youth
  • Poly Drug, alcohol users teens
  • Dual Disorders
  • MDs role in Rx misuse
  • Aging Floridians and Addictions
  • Health Providers-MDs role in failure to Dx
  • ED-ERs role in failure to DX and intervene
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