Transcript S. Alex Stalcup, M.D.

S. Alex Stalcup, M.D.
New Leaf Treatment Center
251 Lafayette Circle, Suite 150
Lafayette, CA 94549
Tel: 925-284-5200
Fax: 925-284-5204
[email protected]
www.nltc.com
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.
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.
Neuroadaptation, Tolerance,
and Withdrawal
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Neuroadaptation is the brain’s response to over stimulation from drugs. Drug-specific circuits cause a
mixture of sedation and stimulation or intoxication.
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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.
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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.
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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
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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.
Definition of Addiction
• Compulsion: loss of control
The user can’t 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.
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.
Entrance into System
Arrest
Psych Emergency
Emergency Room
Domestic Violence
Family Court
Probation - Parole
Schools
Assessment
Monitoring and Treatment
In-custody Treatment
Residential Treatment
IOP + Sober Living
Intensive Outpatient
IOP
Addict
Entry
Assessment
? Unsure
(Positive UDS)
Monitoring
Random UDS
6 tests/90 days
Re-entry
Monitoring
Random UDS 6 months
Discharge
Discharge
National Survey on Drug Use and Health Statistics 2007
Prescription Drug
Abuse
• Opiate pain medications
• Benzodiazepine tranquilizers
• Prescription stimulants
(Adderall, Ritalin)
• Sleeping pills, muscle relaxants
Sentinel Events in
Prescription Drug Abuse
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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
National Survey on Drug Use and Health Statistics 2007
National Survey on Drug Use and Health Statistics 2007
QuickTime™ and a
decompressor
are needed to see this picture.
“You’ve Got Drugs V” Prescription Drug Pushers on the Internet. National Center on Addiction and
Substance Abuse, Columbia University 2008
Prescription Opiates
Generic: Brand Name
Codeine w/acetaminophen
Hydrocodone:Vicodin, Lortab, Norco
Hydromorphone: Dilaudid
Oxycodone: Percodan, OxyContin
Morphine sulfate: MS Contin
Fentanyl: Duragesic (transdermal), Actiq
Non Tolerant 24 hr. dose
500 mg
20mg-60 mg
20 mg-60 mg
20 mg-60 mg
30 mg-60 mg
25 mcg-50 mcg
Tolerant Users only
Morphine sulfate: MS Contin
Fentanyl: Duragesic (transdermal)
Methadone: Methadose
Buprenorphine: Suboxone, Subutex
Tolerant 24 hr. dose
60 mg-upward
75 mcg-300 mcg
60 mg-300 mg
6 mg-32 mg
Opiate progression from pills
to the needle
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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
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
Prescription Tranquillizers
Dose Equivalent To Alcohol
(2oz liquor or 2 glasses of wine or 2 cans of beer)
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Alprazolam (Xanax®)
Diazepam (Valium®)
Chlordiazepoxide (Librium®)
Clonazepam (Klonopin®)
Lorazepam (Ativan®)
Temazepam (Restoril®)
• Butalbital (in Fiorinal®)
• Carisoprodol (Soma ®)
• Zolpidem (Ambien®)
0.5- 1mg
10mg
25mg
1-2mg
2mg
30mg
100mg
350mg
10 mg
Sedative-Hypnotic Effects
Effects
• Calm Euphoria
• Release of Inhibitions
• Sleep Inducing
Withdrawal
• Dysphoria *
• Anxiety *
• Insomnia *
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Sweating (Diaphoresis) *
Tremor
Tachycardia
Hypertension
Hyperventilation
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Elevated temperature
Hallucinations
Seizures
Delirium tremens
Sedation/Sleepiness
Slurred Speech
Unsteady gait (Ataxia)
Confusion
Forgetfulness
Slows heart rate
Decreases blood pressure
* Symptom may continue for months
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.
Medications for
Stimulant Dependence
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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
Seroquel
50-300 mg
25-100 mg
Imipramine
100-200 mg
• Disorders of Thought
Abilify
Haldol
Risperdal
2-10 mg
1-2 mg
1-3 mg
Are you at Risk?
BPSM
The Bio-Psycho-Social Model
EWMS
Environment
Withdrawal
Mental Health
Stress
Bio-Psycho-Social
Model
• Predisposition
Genetics
Childhood Sexual Abuse
Mental Illness
Acquired Hypofrontality
in utero alcohol/drug exposure
perinatal asphyxia
low birth weight
head injury
• The Drug / Circumstances of First Use
• Enabling System
C I M Model Treatment
Causes of Craving
E
W
M
S
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Environmental cues (Triggers)
immediate, catastrophic, overwhelming craving stimulated by people,
places, things associated with prior drug-use experiences
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Drug Withdrawal
inadequately treated or untreated
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Mental illness symptoms
inadequately treated or untreated
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Stress equals craving
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.
Bio-Psycho-Social Model
Are you at Risk?
Apply B P S M (bio-psycho-social model) to yourself:
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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?
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?
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Is your use causing adverse consequences: grades, friends, money, health,
unwanted sexual behavior?
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Do you crave the drug under addiction conditions: Environment,
Withdrawal, Mental Health, Stress (EWMS)
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If so, when you crave the drug, can you talk yourself into using it, even
when you have resolved to not use?
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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?
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.
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?
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.
Addiction: Risk & Resilience
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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
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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
REFERENCES
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--- Responsibility and choice in addiction. Psychiatric Services. 53(6):70713 (2002).
Bechara A. Decision making, impulse control and loss of willpower to
resit drugs: a neurocognitive perspective. Nature Neuroscience. 8:1458-63
(2005)
Dackis C, O’Brien 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. 38:235-44, 2006
Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights
from imaging studies. The Journal of Clinical Investigation. 111(10:144451 (2003).
Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in
progress. National Campaign to Prevent Teen Pregnancy. June 2005.