Transcript Addiction & Anxiety: A Common Clinical Conundrum

Addiction & Anxiety:
A Clinical Challenge Hiding an
Opportunity
Robert L. DuPont, M.D.
President, Institute for Behavior and Health, Inc.
www.ibhinc.org
National Council on Alcoholism and Drug Dependence
Maryland Chapter
Tuerk Conference
May 10, 2011
The Two Pillars of My 44-Year Career
Addiction
▫ 1973 – 1978: First Director of the National
Institute on Drug Abuse (NIDA)
▫ 1973 – 1978: Second White House Drug
Czar under Presidents Nixon and Ford
▫ 1978 – Present: President of the Institute
for Behavior and Health, Inc.
Addiction
▫ Worked closely with the 4 other heads of
NIDA and the 11 other White House Drug
Czars
▫ The only White House Drug Czar to serve
two presidents and the only head of NIDA
to serve as White House Drug Czar
▫ The Selfish Brain: Learning From
Addiction published by the American
Psychiatric Association and by Hazelden
Anxiety
▫ 1980-1984: Founding President of the Anxiety
Disorders Association of America (www.adaa.org)
▫ The Anxiety Cure: An 8-Step Program for Getting
Well, and The Anxiety Cure for Kids: A Guide for
Parents
▫ Both books published by John Wiley & Sons and
written with my daughters: Elizabeth DuPont Spencer,
LCMSW and Caroline M. DuPont, M.D.
▫ Published more than 300 professional articles,
chapters, book reviews and editorials plus 18 books
and monographs on addiction and anxiety
Most Important Qualification
• Clinical practice in same place for four decades
▫ Many of my patients suffered from either
addiction or anxiety, or often from both
▫ Many patients seen over decades
▫ Some families over three generations
This is a Talk by a Clinician
• For Clinicians
• To help physicians help their many patients who
suffer intensely from BOTH addiction and
anxiety
• To help these patients manage their serious,
lifelong biological disorders
The Connection of Addiction & Anxiety
• Failure to sort out this connection commonly
defeats the treatment of both disorders
• The connection confuses both diagnosis and
treatment – for clinicians and for patients
The Connection of Addiction & Anxiety
• Substance Use Disorders (SUDs) and Anxiety
Disorders (ADs) are the two most prevalent
groups of mental disorders (even more than
depression)
▫ Far more prevalent than anything else
▫ About a quarter of the US population during their
lifetimes meet diagnostic criteria for anxiety and
separately for Substance Use Disorders
The Connection of Addiction & Anxiety
• There is a substantial but not majority overlap
(comorbidity)
• Both have peak onset in teenage and young adult years
• Both are familial with genetic components
• The prevalence of both declines modestly with age
thereafter
• When comorbid the Anxiety Disorder often comes first –
in childhood or the early teenage years
Anxiety Disorders are Mostly Female and
Substance Use Disorders are Mostly Male
• Another difference is commonly seen in
teenagers in terms of the risk of Anxiety
Disorders vs. the risk of Substance Use
Disorders
▫ Many people who are destined to have Anxiety
Disorders from an early age are worried about
future consequences and want to please people in
authority
▫ In contrast many young people at high risk of
Substance Use Disorders are risk takers who are
more concerned with peer approval than with the
opinions of authorities or adults
Example
• A simple behavior often separates these two
groups in adolescence: homework
▫ Most anxious kids are eager to do their homework
fearing criticism if they don’t while many youth
who are at high risk for SUDs are not motivated to
do homework
• Another commonly seen difference: young
people who have ADs are often compulsively
honest and many young people who have SUDs
are quick to lie
Comorbidity of Addiction & Anxiety is
Common
• But in their lifetimes most people with SUDs do not
meet criteria for ADs, and
• Most people with ADs do not meet criteria for SUDs
• Clinicians often fail to recognize that comorbidity is
the exception not the rule because the comorbidity
is so common and so often frustrates treatment
• The more severe and crippling the disorder the more
the comorbidity – that is why clinicians see more
comorbidity than the community epidemiology
identifies
Lifetime and 12-Month Prevalence of UM-CIDI/DSM-III-R Disorders*
Male
Female
Lifetime
Disorders
12 mo
Lifetime
Total
12 mo
Lifetime
12 mo
%
SE
%
SE
%
SE
%
SE
%
SE
%
SE
Affective disorders
Major depressive episode
Manic episode
Dysthymia
Any affective disorder
12.7
1.6
4.8
14.7
0.9
0.3
0.4
0.8
7.7
1.4
2.1
8.5
0.8
0.3
0.3
0.8
21.3
1.7
8.0
23.9
0.9
0.3
0.6
0.9
12.9
1.3
3.0
14.1
0.8
0.3
0.4
0.9
17.1
1.6
6.4
19.3
0.7
0.3
0.4
0.7
10.3
1.3
2.5
11.3
0.6
0.2
0.2
0.7
Anxiety disorders
Panic disorder
Agoraphobia w/o panic disorder
Social phobia
Simple phobia
Generalized anxiety disorder
Any anxiety disorder
2.0
3.5
11.1
6.7
3.6
19.2
0.3
0.4
0.8
0.5
0.5
0.9
1.3
1.7
6.6
4.4
2.0
11.8
0.3
0.3
0.4
0.5
0.3
0.6
5.0
7.0
15.5
15.7
6.6
30.5
1.4
0.6
1.0
1.1
0.5
1.2
3.2
3.8
9.1
13.2
4.3
22.6
0.4
0.4
0.7
0.9
0.4
0.1
3.5
5.3
13.3
11.3
5.1
24.9
0.3
0.4
0.7
0.6
0.3
0.8
2.3
2.8
7.9
8.8
3.1
17.2
0.3
0.3
0.4
0.5
0.3
0.7
12.5
20.1
5.4
9.2
35.4
0.8
1.0
0.5
0.7
1.2
3.4
10.7
1.3
3.8
16.1
0.4
0.9
0.2
0.4
0.7
6.4
8.2
3.5
5.9
17.9
0.6
0.7
0.4
0.5
1.1
1.6
3.7
0.3
1.9
6.6
0.2
0.4
0.1
0.3
0.4
9.4
14.1
4.4
7.5
26.6
0.5
0.7
0.3
0.4
1.0
2.5
7.2
0.8
2.8
11.3
0.2
0.5
0.1
0.3
0.5
5.8
0.6
0.6
0.1
…
0.5
…
0.1
1.2
0.8
0.3
0.2
…
0.6
…
0.2
3.5
0.7
0.3
0.1
…
0.5
…
0.1
1.5
31.2
1.3
48.0
1.1
29.5
1.0
Substance use disorders
Alcohol abuse w/o dependence
Alcohol dependence
Drug abuse w/o dependence
Drug dependence
Any substance
abuse/dependence
Other disorders
Antisocial personality
Nonaffective psychosis#
UM-CIDI
indicates
University of Michigan Composite International
NCS National Comorbidity
Survey
Any
NCS
disorder
48.7 Diagnostic
0.2Interview; 22.7
0.9
47.3
#
*
Nonaffective psychosis includes schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, and atypical psychosis
Kessler et al., 1994
Lifetime prevalence of comorbid mental and addictive disorders in the United
States, noninstitutionalized household population ages 15-54, 1990.
Kessler et al., 1995 – submitted for publication
Conditional probabilities of 12-month co-occurrence of addictive and mental disorders
MD
Any ADD
Addictive Disorder
Mental Disorder
Affective
MDE
DY
Mania
Any
22.9
2.4
1.7
24.5
18.4
18.8
37.1
18.3
Anxiety
GAD
PD
PTSD
SO PH
SI PH
AGO
Any
8.1
4.5
8.3
16.6
14.5
8.4
35.6
21.0
16.0
17.7
17.4
13.5
17.7
15.2
Any Mental
One +
42.7
14.7
Kessler et al., 1994
Some Similarities & Some
Differences of Clinical Importance
Lifetime Diagnosis of:
Male
Female
Total
Any Substance Use Disorder
35.4%
17.9%
26.6%
Any Anxiety Disorder
18.2%
30.5%
24.9%
Any Affective Disorder
14.7%
23.9%
19.3%
Both Substance Use Disorders &
Anxiety Disorders
• Are serious and disabling “brain diseases”
• Characterized by feelings that are driven by disturbed
brain biology
• Have specific maladaptive behaviors
• Encourage the patient and the physician to want to erase
or eliminate the disorder
▫ This is seldom possible
• Cured by “knowing what is wrong and what to do about
it”
The Patients’ Challenge
• Overcoming both SUDs and ADs means overcoming powerful
brain processes that virtually compel their distinctive
pathological behaviors
• Both require patients to voluntarily endure discomfort in the
short-term to achieve health in the long-term
• The motto “You alone can do it, but you cannot do it alone”
applies to both addiction and anxiety
• Medicine is far more important in the treatment of Anxiety
Disorders than in the treatment of Substance Use Disorders
• Community Support Groups are far more important in SUDs
Addiction
• What are the SUD patient’s clinical problems?
▫ Staying stopped from the use of alcohol and other
drugs of abuse
 The addicted patient is caught in an abusive
chemical love affair that is driven by the brain’s
reward system and enabled by distorted thinking
 The most relevant brain locations for addiction: the
Nucleus Accumbens and Ventral Tegmental Areas
with Dopamine the major neurotransmitter
The Key Features of Addiction to
Alcohol & Other Drugs
• Continued use despite problems, and
• Dishonesty
▫ The addict manages all strong feelings including, but
not limited to anxiety, with substance use
▫ Brain reward erases negative feelings of all kinds
▫ Alcohol and drug use produce short-term good
feelings and long-term bad feelings
 A clinically relevant paradox
Addictive Disease
• Caused by repeated chemical stimulation of
brain reward
• The addicted brain demands more of this
stimulation – at just about any cost
• The addicted brain high jacks the higher-level
brain functions producing distorted thinking
including denial and dishonesty
The One Word Antidote to Addiction
• HONESTY
▫ Honesty works because it overcomes the high-jacked
thinking produced by addiction
▫ Dishonesty is universal in addiction
 Because people who care about the addicted person try to
get the person to stop alcohol and drug use
 The addicted person wants to hold on to these
relationships AND to the chemical lover
 The only way to do that is to lie
What Can a Clinician Do to Help an
Alcoholic or Drug Addict Get and Stay Well?
• Firmly educate the patient, and when possible
the others around the patient, about the nature
of the disease of addiction and the challenging,
lifelong path to abstinence and recovery
• Support the patient and those who care about
the patient in this perilous endeavor
▫ With determination, respect and patience
Abstinence
• Recovery starts with abstinence from the use of
alcohol and other drugs of abuse (chemical
stimulation of brain reward)
▫ The practical strategy for achieving that elusive
goal
 Often means intensive substance abuse treatment
 12-step meetings and working the program
 Building a new life – Recovery
One Major Factor in Outcome
• Long-term, intensive monitoring for any alcohol
and/or drug use linked to swift, certain, but not
necessarily severe consequences
• Dramatically improves outcomes – as in the
nation’s Physician Health Programs
Clinically Significant Anxiety
• The problem defined
▫ An excess of worry that is painful and disabling
▫ A disease of future thinking
• The brain biology of Anxiety Disorders
▫ The Locus Coeruleus (the brain’s novelty detector)
signals danger
▫ Norepinephrine – the key neurotransmitter
involved in anxiety
▫ In the Anxiety Disorders the normal alarm
mechanism sends false signals of danger
Why Are There Many People with
Anxiety Disorders?
• Because there is a lot to worry about and people
who don’t worry suffer terrible consequences
• In Anxiety Disorders worry is excessive and
often crippling – analogous to an autoimmune
disease
• Even worse for many patients, although they do
not kill patients, the Anxiety Disorders are
terribly painful and rob the patients of the
enjoyment of their lives
What is the Treatment for Anxiety
Disorders?
• Cognitive Behavioral Treatment (CBT)
▫ Change the meaning of the symptoms
 They are distressing but not dangerous
▫ Change the behavior
 Go toward the stimulus of fear – do not avoid it
What is the Treatment for Anxiety Disorders?
• Medication
▫ The use of antidepressants now dominate the
treatment of the anxiety disorders
▫ The same medicines that work for depression work for
anxiety generally over the same delayed onset time
course and at the same dose levels
▫ No risk of abuse because these medicines do not
produce brain reward
 The antidepressants require single daily doses leading to
delayed but powerful and often subtle reductions in
anxiety
 This effect is dramatically different from the way drugs of
abuse reduce anxiety – with an exploding hand grenade
Benzodiazepines (BZs)
• The benzodiazepines are effective treatments for
Anxiety Disorders for patients without
Substance Use Disorders – either on a regular
basis or as needed
• Unlike the antidepressants, the benzodiazepines
work within half an hour of dosing and have an
effective half life of about 6 to 8 hours
• The therapeutic effect of the benzodiazepines,
while not as dramatic as the use of abused drugs,
is relatively fast and closely tied to the dose itself
Benzodiazepines
• Not associated with brain reward when used
therapeutically
• With substance abuse patients the
benzodiazepines used to treat anxiety are
analogous to the treatment of pain with opiates
in addicted patients
▫ In both anxiety and pain the use of these
medicines is a high risk endeavor because both
classes of medicines are easily used nonmedically
Benzodiazepines Differentiate Anxiety
Disorders With and Without Addiction
• Because repeated administration of BZs rapidly
produces tolerance to brain reward
▫ But not to anti-anxiety effects
▫ Addicted patients take high and escalating doses
with alcohol and other drugs
▫ Non-addicted anxious patients never escalate their
BZ dose beyond common clinical doses and do not
use BZs with alcohol and other drugs
The Stop Lights on Benzodiazepine Use
Total 24-Hour Dose Zones for the Most
Commonly Used Benzodiazepines
Green Light
Zone
Yellow Light
Zone
Red Light
Zone
Ativan
(lorazepam)
Up to 5 mg/day
Greater than 5 mg up
to 10 mg/day
Greater than 10
mg/day
Klonopin
(clonazepam)
Up to 2 mg/day
Greater than 2 mg up
to 4 mg/day
Greater than 4
mg/day
Valium
(diazepam)
Up to 20 mg/day
Greater than 20 mg up Greater than 40
to 40 mg/day
mg/day
Xanax
(alprazolam)
Up to 2 mg/day
Greater than 2 mg up
to 4 mg/day
Greater than 4
mg/day
Xanax XR
(alprazolam)
Up to 3 mg/day
Greater than 3 mg up
to 6/mg day
Greater than 6
mg/day
Addiction to BZs
• Addiction is signaled by dishonesty and
continued use despite problems
▫ At high and unstable doses with poor response
• Non-addicted use is signaled by stable low doses
with excellent response
Dealing with Comorbidity of Addiction
& Anxiety
• Why is there so much comorbidity?
▫ Substance abuse causes anxiety and in patients
with Anxiety Disorders makes their anxiety worse
▫ The distress of Anxiety Disorders is overcome, in
the short-term, by the substance use – alcohol for
example does reduce social anxiety in the short
term
When Confronting Comorbid Addiction
& Anxiety
• Prioritize Abstinence
• Simple advice, hard for patients and physicians to take,
consistently
• Because the patients are greatly distressed by anxiety
and because they want it gone
• Treatment of Anxiety Disorders involves changing
thinking about anxiety – changing the meaning of the
distress
▫ “Panic attacks are just a few chemicals in my brain
temporarily out of place”
When Confronting Comorbid Addiction
& Anxiety
• If the comorbid patient continues to use alcohol and
other drugs of abuse no treatment for the Anxiety
Disorder will work
• The recovery from addiction is prolonged by a
preoccupation with patients’ discomfort with their
anxiety
• Even worse, the search for relief from anxiety
commonly becomes an excuse for continued use of
alcohol and drugs and a distraction from the task of
achieving abstinence
When Confronting Comorbid Addiction
& Anxiety
• Setting the goal of treatment as getting rid of
anxiety, like getting rid of addiction, is a dangerous
mirage that seduces both patients and physicians
• Both are lifelong biological disorders
• Both require lifelong management
▫ Patients need strategies to achieve “brain
management”
▫ On autopilot the brain continues both diseases and
deepens the suffering
Brain Management
• Means taking control manually to do the things that
the selfish brain does not want
▫ In addiction that means not using
▫ In anxiety that means feeling the fear and doing it
anyway
▫ In both cases denial of the disorder thwarts recovery
and acceptance of the seriousness and the lifelong
nature of the disorder is the prerequisite for getting
well
Common Errors of Physicians Who
Mostly See Addicted Patients
• Assume that everyone with addiction has an
Anxiety Disorder
• Assume that once clean and sober the anxiety
will always disappear
• Assume that medicines will eliminate the
patients anxiety once sobriety is achieved
Common Errors of Physicians Who
Mostly See Anxiety Disorder Patients
• Fail to recognize addiction
• When it is seen, treat it as a symptom of anxiety
• Prioritize anxiety treatment over abstinence
• Assume that when anxiety is treated the “selfmedication” with alcohol and drugs will
disappear
• The wisest course of action is to treat comorbid
Anxiety Disorders and Substance Use Disorders as
two separate conditions (not one secondary to or
derivative of the other) using specific treatments for
each disorder
• There are no better patients than those with
addiction and anxiety
▫ When addiction and anxiety are combined the
challenges and the stakes are higher for both the
patient and the physician
▫ So are the rewards for both
References
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