Transcript Addiction Myths

Addiction
Myths and
Science
David Kan, MD
San Francisco, Department of
Veteran Affairs
Overview
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Understand the science of
addiction and its relationship to
other medical diseases
Understand the concepts of relapse
and recovery
Describe disease-specific
treatment of addiction including
medication assisted treatment
Myths of Addiction
Treatment
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Myth of Self-Medication
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Treating “underlying” disorders tends not
to work
Depression doesn’t make you drink
BUT, drugs do make you feel good
(however, less and less over time)
Myths of Addiction
Treatment
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Myth of Self-Medication
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Myth of Character Weakness
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Weakness or willpower have little to do
with becoming addicted
Educated, strong people succumb to the
best drugs in the world
Myths of Addiction
Treatment
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Myth of Self-Medication
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Myth of Character Weakness
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Myth of Holding One’s Liquor
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The “Wooden Leg” Syndrome predicts
alcoholism, not immunity to alcoholism
Myths of Addiction
Treatment
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Myth of Self-Medication
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Myth of Character Weakness
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Myth of Holding One’s Liquor
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Myth of Detoxification
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Getting sober is easy
Staying that way is incredibly difficult
Detoxification is preparatory step to further
treatment
Myths of Addiction
Treatment
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Myth of Self-Medication
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Myth of Character Weakness
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Myth of Holding One’s Liquor
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Myth of Detoxification
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Myth of Brain Reversibility
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Addiction produces permanent neurotransmitter
and chemical changes
“Kindling” increase risk of permanent paranoia and
hallucinations (from alcohol and stimulants)
Facts of Addiction
Treatment
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Addiction is a brain disease
Chronic, “cancerous” disorders
require multiple strategies and
multiple episodes of intervention
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Treatment works in the long run
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Treatment is cost-effective
Common Characteristics of
Addict-Criminal Offenders
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Unemployment
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Criminal justice recidivism
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Inability to cope with stress or
anger
Highly influenced by social peer
group
Inability to handle high-risk relapse
situations
Common Characteristics…
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Emotional and psychological
immaturity
Difficulty relating to family
Inability to sustain long-term
relationships
Educational and vocational deficits
Addiction is a Brain Disease
…with biological,
sociological and
psychological
components
Nature of Addiction
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Loss of control
Harmful
Consequences
Continued Use
Despite
Consequences
Three “C’s” of Addiction
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Control
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Compulsion
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Early social/recreational use
Eventual loss of control
Cognitive distortions (“denial”)
Drug-Seeking activities
Continued use despite adverse consequences
Chronicity
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Natural history is of multiple relapses preceding stable
recovery
Relapse after years of sobriety is possible
Compliance & Chronicity
Chronic
Illness
Medication
Compliance
Relapse
within 1 yr.
Diabetes
<60%
30-50%
Hypertension
<40%
50-70%
Asthma
<40%
50-70%
Addiction
30-50%
McLellan AT, Lewis DC, O’Brien CP, Kleber HD;
Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000
Abstinence
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Strictly speaking, abstinence is
developed, not recovered
It is an abnormal condition, signifying
an internal defect (disease)
Addicts want to be “normal,” that is,
using drugs in control
Self-Control
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Addicts seek control, not
abstinence
Self-Control
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Addicts seek control, not
abstinence
If I can have
just one, then
I will be
normal, just
like my friends
What is recovered in
Recovery ?
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Abstinence
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Range of Emotions
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Intimacy
Addiction Risk Factors
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Genetics
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Young Age of Onset
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Childhood Trauma (violent, sexual)
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Learning Disorders (ADD/ADHD)
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Mental Illness
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Depression
Bipolar Disorder
Psychosis
Alcohol 101
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Genetics = 60% of Risk
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Males >> Females
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Available Medications
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Antabuse (Disulfiram):
ReVia (Naltrexone):
Vivitrol (Naltrexone):
Campral (Acamprosate)
Effective Treatments
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12-Step
Cognitive-Behavioral Therapy
Counseling
Deterrence
Relapse Prevention
Relapse Prevention
Relapse Prevention
Alcohol:
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Rate of Metabolism = 1.0-1.5 standard
drinks per hour
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Beer
Wine
Liquor
12.0 oz.
05.0 oz.
01.5 oz
5% ABV
12.5% ABV
40% ABV
2nd and 3rd DUI/DWI’s are more
diagnostic than 1st
Intoxication increases risk of suicide
and homicide
Alcohol: Cognitive Deficits
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Memory Disorders
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Impaired Abstraction
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Perseveration using failed problemsolving strategies
Loss of Impulse Control
“Alcoholic Dementia” is similar to
Alzheimer’s, but shows some
improvement with sobriety
Biological Lens
Genetic predisposition
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60% of alcoholism variance is predicted by
genetics
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•
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Animal Breeding Studies
Family Tree Studies
Adoption and Twin Studies
High-Risk Inheritance Paradigms
Neurotransmitters shifts
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Dopamine & Reward Pathways
Genetic Inheritance
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Human Family Tree Studies
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Alcoholism runs in families
“Drunks beget drunkards” – Plutarch 60 A.D.
Males have higher rates of alcoholism than
females
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Females may have more depression
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Males show more antisocial behaviors
Genetic Inheritance
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Twin Adoption Studies
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Alcoholic family twin raised by nonalcoholic foster parents
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4X increase in alcoholism for males
9X increase if father is antisocial
Non-alcoholic family twin raised by
alcoholic foster parents
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No increased risk
Cocaine 101
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Freebase (crack) since 1985
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No medications are effective
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Psychosocial treatments, including
Cognitive-Behavioral Therapy and
Relapse Prevention are effective
Risk of permanent “kindling” of
paranoia and hallucinations
Cocaine: Functional Imaging
Methamphetamine
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Synthetic made from ephedrine
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Long-Acting, up to 12+ hours
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Paranoia, Auditory Hallucinations
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“Burnt-Out Speed Freak”
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Persistent paranoia and hallucinations
Anhedonic lack of pleasure
The Brain
Hijacking the Reward System
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Food
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Sex
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Excitement
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Comfort
Dopamine Spells REWARD
Brain Reward Pathways
Activation of Reward
Heroin 101
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New production in South America
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High purity/potency (smokeable)
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Detoxification is of limited long-term efficacy
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Most effective treatment for chronic users is
Methadone Maintenance
Medications
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Methadone, LAAM
Buprenorphine
Naltrexone
Replacement
Replacement
Opioid Blockade
Death Rates in Treated
and Untreated Addicts
8
% Annual Death Rates
7
6
OBSERVED
EXPECTED
5
4
3
2
1
0
MMT
VOL DC TX
INVOL DC TX
Slide data courtesy of Frank Vocci, MD, NIDA –
Reference: Grondblah, L. et al. Acta Pschiatr Scand, P. 223-227, 1990
UNTREATED
Impact of MMT on IV Drug Use for
388 Male MMT Patients in 6 Programs
ADMISSION
100
*
*
0
Pre-
| 1st Year
| 2nd Year
| 3rd Year
| 4th
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
Crime among 491 patients before
and during MMT at 6 programs
Before TX
During TX
Crime Days Per Year
300
250
200
150
100
50
0
A
B
C
D
E
F
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
Relapse to IV drug use after MMT
105 male patients who left treatment
Percent IV Users
100
82.1
80
72.2
60
57.6
45.5
40
28.9
20
0
IN
1 to 3
4 to 6
7 to 9
10 to 12
Months Since Stopping Treatment
Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991
Opioid Agonist Treatment of Addiction - Payte - 1998
Twelve-Step Groups
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Myths
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Only AA can treat
alcoholics
Only a recovering
individual can treat an addict
12-Step groups are intolerant of
prescription medication
Groups are more effective than
individuals because of confrontation
Twelve-Step Groups
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Facts
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Available 7days/week, 24 hrs/day
Work well with professionals
Primary treatment modality is
fellowship (identification)
Safety and acceptance predominate
over confrontation
Offer a safe environment to develop
intimacy
Therapeutic Communities
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Cost-effective, long-term care
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Effective in treating sociopathic,
anti-social personalities
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Often very confrontational and
dogmatic
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Risks of charismatic leadership &
program corruption
Public Health
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Drug treatment is disease
prevention
HIV Infection reduced 6-fold in
injecting drug users
>90% injection drug users are
infected with Hepatitis C virus
How Long Should
Treatment Last ?
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Depends on patient problems/needs
Less than 90 days is of limited or no
effectiveness for residential /
outpatient setting
A minimum of 12 months is required
for methadone maintenance
Longer treatment is often indicated
Coercion
Treatment does not need to be
voluntary to be effective.
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Court-Ordered Probation
Family Pressure
Employer Sanctions
Medical Consequences
“Costly” or “Cost-Effective”
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Expensive Incarceration: Treatment is less
expensive than not treating or incarceration
(1 year of methadone maintenance = $3,900 vs.
$25,900 for imprisonment)
1:7 Rule: Every $1 invested in treatment = up to
$7 in reduced crime-related costs
Health Offset: Savings can be > 1:12 when health
care costs are included
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Reduced interpersonal conflicts
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Improved workplace productivity
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Fewer drug-related accidents
Treatment Effectiveness
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Drug dependent people who participate in
drug treatment
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Decrease drug use
Decrease criminal activity
Increase employment
Improve their social and intrapersonal functioning
Improve their physical health
Drug use and criminal activity decrease for
virtually all who enter treatment, with
increasingly better results the longer they stay
in treatment.
Medical Detoxification
Medical detoxification is only the
first stage of addiction treatment
and by itself does little to change
long-term drug use.
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High post-detoxification relapse rates
Not a cure !
A preparatory intervention for further care
Medications
Medications are an important element
of treatment for many patients,
especially when combined with
counseling and other behavioral
therapies.
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Alcohol:
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Opiates:
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Nicotine:
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Stimulants:
Naltrexone, Disulfiram,
Acamprosate, Odansetron
Naltrexone, Methadone,
Buprenorphine
Nicotine replacement (gum,
patches, spray), bupropion
[None to date]
Discussion
End