Flora Sadri DOMPH FAAFP Area Medical Director CleanSlate Centers Kentucky Academy of Family Physicians August 4 2017 Flora Sadri DO MPH FAAFP Area Medical Director CleanSlate Centers ID: 652320
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Slide1
Addiction: A Chronic Brain Disease
Flora Sadri, DO,MPH, FAAFP
Area Medical Director,
CleanSlate
Centers
Kentucky Academy of Family Physicians
August 4, 2017Slide2
Flora Sadri, DO, MPH, FAAFP
Area Medical Director,
CleanSlate
Centers
President, Massachusetts Academy of Family Physicians
Chair, Commission on Government and Advocacy, American Academy of Family Physicians (AAFP)
Vice Chair, Legislative Advocacy Committee, American Society of Addiction Medicine (ASAM)Slide3
ASAM’s 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.
O reward and/or relief by substance use and other behaviors.Slide4
Addiction: Changes in the Brain
A
chronic, relapsing brain disease
Drugs change brain structure and function
Brain changes can be long-lasting Slide5
Addiction is a chronic brain disease
Federal government: (Surgeon General, NIDA, SAMHSA, NIAAA)
Physician Organizations: (AMA, ASAM,
etc
)
NOTE:
not everyone with a substance use disorder has the disease of addiction
not everyone who appears drug seeking/doctor shopping has the disease of addiction
not everyone who uses illicit drugs has the disease of addiction, or a substance use disorder – how do you
kow
it when you see it?Slide6
American Society of Addiction Medicine (ASAM) Addiction Definition, April 2011
American Society of Addiction Medicine (ASAM) Addiction Definition, April 2011
Affects neurotransmission such that addictive behaviors replace healthy self-care related behaviors
Genetics account for 50% of addiction development
Significant self-deception
Disruption of healthy supports and problems in interpersonal relationships
History of trauma or stressors that overwhelm an individual’s coping abilities
The presence of co-occurring psychiatric illness
Distortion in meaning, purpose and values that guide attitudes, thinking and behavior
The effects to the brain allow external cues to trigger craving and drug use
Persistent risk of and/or recurrence of relapse
Impaired executive function so that perception, learning, impulse control., compulsivity and judgment are impaired.
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitrySlide7
SUBSTANCE USE DISORDER (SUD)
Symptoms are in four major categories
Impaired control
Social impairment
Risky use
Tolerance and withdrawalSlide8
4 C’s of Addiction
C
ompulsive
Use
C
ontinued Use Despite Harm
Loss of
C
ontrol
C
ravingsSlide9
Risk factors for developing addiction
We can impact 2 out of 3
And lack of exposure to the substance means the brain will not develop addiction to the substanceSlide10Slide11
Genetics Account for 50% of
Risk of AddictionSlide12
Emotional
neglect
Abuse
Adverse
childhood
experiences
Household
dysfunction
Adverse Childhood Experiences
Emotional Neglect
Abuse
Household DysfunctionSlide13
Risk factors for developing addiction
We can impact 2 out of 3:
Early exposure
(community based resiliency training)
Traumatic childhood due to abuse/neglect/missing parenting
(treating adults with addiction helps prevent their kids from being addicted)
And Iatrogenic Addiction can be prevented:
Lack of any brain exposure prevents the brain's addiction to the substance
The minority of overdose deaths are under age 25. This is an epidemic impacting middle aged and older adultsSlide14Slide15
Act First, Think Later
More Risky
Impulsive Behavior
Less than Optimal Planning
Preference for Physical Activity and Sensation Seeking
Emotions Felt Very Intensely
Strongly Influenced by Friends and Peers
Less Consideration of Negative Consequences
This is Normal DevelopmentSlide16Slide17
Rate of Change
Brain Development
Source:
Tapert & Schweinsburg, 2005Slide18
Dopamine ReceptorsSlide19Slide20
Synaptic RefinementSlide21Slide22
MyelinationSlide23Slide24Slide25Slide26
Dopamine Pathways
Serotonin Pathways
Functions
Reward (motivation)
Pleasure, euphoria
Motor function (fine tuning)
Compulsion
Perseveration
Functions
Mood
Memory processing
Sleep
CognitionSlide27
Addiction is a Developmental Pediatric Disease
Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003Slide28Slide29
How Heroin WorksSlide30Slide31Slide32Slide33Slide34Slide35
Opioid Addiction: A Chronic Brain Disease
Goals of treating chronic conditions:
Decrease related morbidity and mortality;
decrease total cost of care
increase functioning / quality of lifeSlide36
Drug Dependence is a Chronic Medical Illness
Diabetes Type I – 60% Medical Adherence
HTN – Less than 40% Adherence
Asthma – Less than 40% Adherence
Drug Abuse – 40% - 60% AdherenceSlide37
Addiction as a Chronic Disease
McLellan AT, Lewis DC, O’Brien CP,
Kleber
HD. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. JAMA. 2000
oct
; 284(13): I168-95.
Addiction
Hypertension
30-60% Genetic
25-50% Genetic
40-60% Relapse
50-70% Relapse
Initial
choices: alcohol/drug
Initial choices: food, activityPotential permanent physiological changesPotential permanent physiological changesAbstinence and medications do not reverse diseaseLifestyle changes and medications do not reverse disease< 50% adhere to drug abstinence 1 year post-treatment< 40% adhere to medication, 30% adhere to lifestyle changesSlide38
FACT OR FICTION
ADDICTION IS A CHOICE?Slide39
FACT OR FICTION
ADDICTION IS A CHOICE
FALSE
ADDICTION IS A DISEASESlide40
Chronic Relapsing Brain Disease
Treat the condition like DM, HTN, CAD, CVD
Long-term abstinence without MAT
<5%
Key elements: empathy, compassion and knowledge
We are passionate about this work because it is the right thing to do for patients and their families
ASAM/ABAM continuing education and mentoring Slide41
FACT OR FICTION
PEOPLE USE BECAUSE THEY JUST WANT TO GET HIGH?Slide42
FACT OR FICTION
PEOPLE USE BECAUSE THEY JUST WANT TO GET HIGH
FALSESlide43
FACT OR FICTION
TAKING SUBOXONE OR METHADONE IS JUST SUBSTITUTING ONE DRUG FOR ANOTHER
?
FALSE!Slide44
FACT OR FICTION
FACT
:
Methadone or Suboxone are the primary treatments associated with decreased opioid addiction related mortality, morbidity, cost of care, and improved functioning.Slide45
RATIONALE FOR MEDICATIONS in ADDICTION TREATMENT (MAT)
Consistent with understanding that Addiction is a Chronic Disease, Maintenance Treatment works!
REDUCES CRAVINGS
DECREASES WITHDRAWAL SYMPTOMS
BLOCKS EUPHORIA FROM OPIATES
DECREASES OPIATE USE
Detoxification is not effective
Inpatient care without ongoing medication leads to increased death risk
Long-term abstinence without MAT
<5%Slide46
FACT OR FICTION
ADDICTS CAN JUST STOP USING IF THEY WANT TO?
“JUST SAY NO”Slide47
FACT OR FICTION
ADDICTS CAN JUST STOP USING IF THEY WANT TO
“JUST SAY NO”
IT’S NOT THAT EASYSlide48Slide49
49Slide50
This is Addiction