Transcript Disease Concept

Harry L. Haroutunian, MD
Physician Director Residential Treatment, Licensed
Professional Program; Clinical Diagnostic Evaluations
DISEASE VERSUS STIGMA
 Is it a moral failing?
 Why are victims of substance abuse still called meth
freaks, junkies, crack heads and garden variety
drunks?
 Addicts are scorned by communities and celebrities
are hounded by paparazzi.
©2007 Betty Ford Center
7/20/2015
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 Government purports to view addiction as a disease ,
but it often works in opposition to that position
through the “War on Drugs”.
 Even the treatment community still-employ
stigmatizing programming and language, such as
when we focus on “dirty” urine.
©2007 Betty Ford Center
7/20/2015
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 Mental illness being misunderstood and stigmatized,
 Addiction and mental health problems are still spoken
of in hushed tones, and patients and their families are
still blamed.
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7/20/2015
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 Concern they will be labeled as an “addict” and the
stigma will stick.
 Often a crisis precipitates treatment, so the problem is
already well-advanced.
 Removing the stigma, guilt and shame from the
equation, people would find it easier to discuss openly
with a health care provider.
 Doctors were slow to recognize addiction as treatable,
and so patients were encouraged to find help outside
of the medical community
 The medical community should recognize unhealthy,
addictive behavior as part of its purview and would
apply evidence-based approaches in their practices.
9 OUT OF 10
PHYSICIANS
IN THE UNITED STATES
MISS THE DIAGNOSIS OF
ADDICTION IN THEIR PATIENTS!
4 OUT OF 5
OF THESE PHYSICIANS
DO NOT
BELIEVE THAT ADDICTION
IS A TREATABLE DISEASE!
Columbia University Study, April 2000
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 It is often routine in mental health practices for
persons with substance misuse problems to be
discharged from treatment when substance misuse is
revealed.
 They are told that the drinking or drug use renders
them “unavailable” for the work of psychotherapy and
they first need to “get clean”.
 Funding for addiction treatment is discriminatory
 Despite passage of Federal Mental Health Parity
legislation, mental health and substance use disorders
continue to be treated differently and often poorly.
 Most of the money that governments spend on “drug
control” is spent on criminal justice interdiction
rather than treatment and prevention.
 A system with stigmatization , blaming, punishing
and making moral judgments instead of providing
treatment and other help that would change behavior.
 Employment, education, insurance and the ability to
vote are all fraught with uncertainty and
discrimination for those in recovery.
 People in recovery have a harder time finding and
keeping jobs, getting licenses, food stamps and
benefits that help their children.
 Having struggled with addiction in the past should not
make life that much more difficult now.
Younger
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7/20/2015
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 Those with alcohol or substance use disorder:
 Odds of having another addictive disorder 7
times greater than rest of population
 Among those with alcohol disorder, 37% have
co-morbid mental disorder
 Among those with drug (not alcohol) disorder
53% with another mental disorder
 Substance Use Disorders
 ~ 35% of psychiatric admissions
 ~ 20% of hospital admissions
 ~ 75% of trauma victims
 ~ 80% of prison population
The Highjacked
Brain
 The brain quickly learns the drug can do this and creates
drug cravings to perpetuate this “Survival” response
 CREB
DELTA FOS B
 The drug becomes the new coping mechanism
 We can not choose not to crave
Addiction Deals with the Midbrain
 The concept of choice is invalid because it does not take
into account patient suffering and craving for survival
 This craving overrides the frontal cortex governing
morals, values and principals
Time Magazine Sept. 2010
 Since 1990 accidental drug overdoses have increased five-
fold
 Has replaced car accidents as the leading cause of
accidental death in 15 states plus the District of
Columbia
 In the late 1990’s a paradigm shift in treating chronic pain
 In 2008 and estimated 25% of 18 – 25 year olds have abused
prescription opiates
 Direct consumer advertising by the
pharmaceutical industry
 Baby Boomer has doubled the use of illicit drug
use since 2002
 From 1998 to 2008 patients seeking treatment for
Opiate abuse rose 400%
70% of Rx
abusers get
their drugs
from family
and relatives –
often for free
and
sometimes
without asking
 85% of the Sites did not require a prescription
for controlled drugs
 Several allowed faxed prescriptions:
 Potential for forgery or multiple use, many
also offered “online consultations”
www.casacolumbia.org
An email from an
“Offshore-Discrete
Pharmacy”
Unintentional Drug Overdose Death Rates
8
600
7
6
400
5
4
300
3
200
2
Sales in mg/person
Crude rate per 100,000
500
Deaths/100,000
Opioid sales
(mg/person)
100
1
0
0
'90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
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Sales rose 90% between 1997 and 2005
In 2005 more than 200,000 lbs of codeine,
hydrocodone, oxycodone, morphine and Demerol.
300 milligrams of painkillers for every person in
America in 2005
Oxycontin sales rose 6 times between 1997 and 2005

Routine use of opioids for treatment of chronic nonmalignant pain conditions - NOT RECOMMENDED (C)

Opioids may be used for select patients (I)

Opioid use for Myofascial pain, fibromyalgia, tender points,
trigger points - NOT RECOMMENDED (I)

Screening of patients prior to initiation of therapy RECOMMENDED (I)
 OPIOIDS, prescribed to treat pain.
 DEPRESSANTS, prescribed to treat anxiety and sleep
disorders.
 STIMULANTS, which are prescribed to treat the sleep
disorder narcolepsy and attention-deficit hyperactivity
disorder (ADHD).
 Morphine
 Opium
 Oxycodone HLC
 Hydrocodone bitartrate, acetaminophen
 Codeine
 Fentanyl/analogs
 Heroin
 Amphetamine
 Cocaine
 Methylphenidate
 Nicotine
 MDMA (methylenedioxy-
methamphetamine)
 Methamphetamine
 Ketamine
 PCP and Analogs
 Flunitrazepam
 GHB
 Methaqualone
 Benzodiazepines
 Barbiturates
 Z-Drugs
K2
SPICE
SMILES
BATH SALTS
SPECIAL K
X
49
 COUGH SUPPRESSANTS
 SLEEP AIDS
 ANTIHISTAMINES
51
53
PreTreatment
The
Interventionist
 Suboxone Detox, Suboxone maintenance
 Naltrexone ETOH, Opioid
 Gabapentin
 Clonidine
 Acamprosate
 Vaccine
 Longer inpatient and extended care programs
 12-Step work and workshops in Trauma, Coda and
Relapse Prevention
 Extended Evaluation Program
 Monitoring based on FSPHP data = better outcome
 Adolescent: 3-6 months with Extended Care
 Chronic Pain
 Psychatric/Behavioral/Addict
 Professional /High Achievers Program
 Trauma Program
 Eating, Gambling and Sex Addiction Programs
 Codependency and Family
 Intervention/Family Education
 Sober Living and Transitional Living
 Sober College; Sober Coach/Companion
 IOP’s
 Drug Courts
 HOPE
 24/7
 Twelve Step abstinence based
 Harm reduction
 Disease Maintenance
 Long term-Twelve Step based abstinence
 with appropriate medically assisted detoxification and
short term medical assistance with the abstinence goal
 Fortified by a select Monitoring Program
 Shifted to tolerate, even promote, individual choices
over behaviors
 New tolerance for diversity, tolerance for drug using
behaviors, exploited by drug sellers

Robert L. DuPont, M.D. Institute for Behavior and Health, Inc.
 Globalized and far more efficient
 Modern drug supply system
 Smoking and intravenous injections
 Greater availability of a wide range of drugs
 Potent routes of administration
 Increased social tolerance for drug use
 Includes a widened range of behaviors from gambling
to sex
 Sweets to credit cards
 The drug problem has been trivialized and meaningful
action has been derailed.
 Debates now occurring about drug policy is to pit law
enforcement against treatment.
 Half of all the people in drug abuse treatment in the
United States are there because they have been forced
in treatment by the criminal justice system.
 Important to respect drug users as people who are
worth of help and compassion, but not respect their
illegal drug use.
 The modern effort to “normalize” illegal drug use,
including comparing it to alcohol and tobacco use
 The 12-Step programs of Alcoholics Anonymous and
Narcotics Anonymous, which have become global
fellowships of recovery, harness both Faith and
Community in brilliant, creative and highly effective
ways.
 Are the ‘secret weapon’ in the public health war against
drug and alcohol addiction

 When you tolerate drug use and when you make drug
use cheaper, easier and safer for the drug user, the drug
use continues and usually escalates.
THANK YOU
Harry L. Haroutunian, MD