Robert Ochsner MD Overview Definition IdentificationStats InheritanceContributing factors Epigenetics Risk Factors Effects on the Brain Treatment Approach Addiction The Great Masquerader ID: 918599
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Slide1
Substance Use Disorders 101
Robert Ochsner, MD
Slide2Overview
Definition
Identification/Stats
Inheritance/Contributing factors
Epigenetics
Risk Factors
Effects on the Brain
Treatment Approach
Slide3Addiction: The Great Masquerader
IT CAN LOOK LIKE ANYTHING
Affective Disorders
Anxiety Disorders
Personality DisordersPsychotic DisordersOrganic and Neurological Disorders
Slide4Slide5The Latest News Headlines on Drug Abuse
CDC Report Finds Overdose Deaths Rose 21 Percent in 2016
Nov. 3, 2017
Breaking Down the Uptick in Adolescent Overdoses
Nov. 3, 2017
Donald Trump Officially Declares Opioid Crisis a Public Health Emergency Oct. 26, 2017
What Is the Opioid Crisis? 5 Facts on the Addiction Epidemic
Oct. 26, 2017
Opioid Crisis Spurs Change at Medical Schools
Oct. 19, 2017
How to Break Unhealthy Habits During Pregnancy
Oct. 5, 2017
Parents: Get Inside Your Adolescent’s Brain to Prevent Addiction
Sept. 28, 2017
CVS to Enforce New Limits on Opioid Prescriptions
Sept. 22, 2017
McCaskill Releases First Findings from Opioids Investigation
Sept. 6, 2017
Slide6Take Action Against Addiction
Slide7As pill mills fade away, heroin fills the void
There are signs that heroin is returning as a cheap alternative to prescription pills, the by-product of Florida’s successful crackdown on pill mills. Read more here: http://www.miamiherald.com/living/article1951397.html#storylink=cpy
Slide823 states have Medical Marijuana Laws (2015)
Slide9Slide10ASAM Definition 2014
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.
Slide11ASAM Definition 2014
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.
Like other chronic diseases, addiction often involves cycles of relapse and remission.
Without treatment or engagement in recovery activities, addiction is progressive and can
result in disability or premature DEATH
.
Slide12DSM-5 Definition: Substance Use Disorders
Using larger amounts or over a longer period of time than intended.
Persistent desire or unsuccessful efforts to cut down or control
Great deal of time spent in obtaining, using, and recovering from
Craving or a strong desire or urge to use
Recurrent use resulting in failure to fulfill major role obligations
Continued use despite persistent or recurrent social or interpersonal problems caused or exacerbated by use
Important social, occupational, or recreational activities are given up or reduced because of use
Recurrent use in physically hazardous situations
Continued use despite knowledge of having a persistent or recurrent physical or psychological problems that is caused or exacerbated by use.
Tolerance defined by need for increased amounts to achieve desired effect or markedly diminished effect with continued use of the same amount
Withdrawal either with withdrawal symptoms, or continued use to relieve or avoid withdrawal
Slide13DSM-5 Definition: Substance Use Disorder
Mild: Presence of 2-3 symptoms
Moderate: Presence of 4-5 symptoms
Severe: Presence of 6 or more symptoms
Slide14non-use use misuse abuse addiction
none moderate substantial heavy
none mild serious severe
ALCOHOL & DRUG CONSUMPTION
ALCOHOL & DRUG PROBLEMS
Continuum Model
Slide15Illicit drug use in America has been increasing, 22.5 million Americans aged 12 or older (8.7% of the population) in 2011, up from 8.3 % in 2002.
US Dept. of Health and Human Services, National Institutes of Health, Nationwide Trends, Dec 2012
Slide16Top Drugs among 8th and 12
th
Graders, Past Year Use
Slide17Source of Prescription Narcotics among Past Year Non-medical Users, 12 Grade
Slide18Stimulants-data from 2014 University of Michigan
Past year non-medical use of the stimulant Adderall remained relatively steady at 6.8 percent for high school seniors.
Slide19Drug Use Among College Students
Data from 2014 University of Michigan
Slide20Slide21Reduced sensitivity to intoxication
Increased sensitivity to social disinhibitions
Greater adverse effects to cognitive functioning
Most certainly YES
Are adolescents more susceptible to alcohol than adults?
Slide22What’s the big deal about kids drinking anyways???
Have you ever seen a group of drunk teenagers?
Demeaning behaviors
Risk taking behaviors
Accidents
Teenage brain effects before 18 yrs old
Slide23Date Rape – one to two-thirds of teen sexual assaults involve alcohol
18% of Females/ 39% Males say it is acceptable for a boy to force sex if the girl is stoned or drunk
40% of children who start drinking before age 15 will become alcoholics
In television 9 out of 10 drinkers are portrayed as having no effects or only positive outcomes from their alcohol consumption
Alcohol and Teenagers:
Slide24Age of Onset & Risk
Slide25Two Powerful Questions
Slide26Inheritance - Genes
Slide27Developmental Issues and Epigenetics
Slide28Prenatal Drug Exposure
Slide29Epigenetics - Methylation
Slide30What is the Field of Epigenetics?
Changes in gene expression that occur by a mechanism other than change to the DNA sequence.
Gene-regulatory information that is not expressed in DNA sequences by transmitted from one generation (of cells or organisms) to the next.
Epigenetics means “above” or “on top of genetics”.
Slide31What Does Epigenetics Mean?
Slide32Epigenetic Modulation
Slide33What Contributes to the Development of
Substance Use Disorders/ Addiction?
Genes/ genetic variation
Account for about 40-50 % of having a substance use problem is genetic. Alcohol liking or disliking is linked—alcohol and aldehyde dehydrogenase
Males are twice as likely as females to have alcohol or drug addictionEnvironmentFamily's beliefs and attitudes – Exposure to Parental SUDsPeer group that encourages drug use
Adverse Childhood Events
Trauma, mental health, physical health, household dysfunction
Age of Onset
Earlier the age of onset of use…
Slide34What Contributes to the Development of Substance Use Disorders/ Addiction?
Adverse Childhood Events
Trauma, Mental health, Physical Health, Household Dysfunction
5 or more childhood events are 7-10 times more likely to report illicit drug use and addiction
Individuals seeking treatment for alcohol use disorders show a high prevalence of childhood adversity and PTSD
Age of OnsetEarlier the age of onset of use…40 % if onset 14 y.o. or younger
10% if onset is 20 years and older
Slide35Risk Factors for Alcohol and Drug Use
Psychiatric
Depression, loneliness, hopelessness
Anxiety
Low self-esteem
Low tolerance for stress
Other mental health disorders
Feelings of desperation
Feelings of loss of control over one’s life
Feelings of resentment
Environment
Male gender
Inner city or rural residence combined with low
socioeconomic status; lack of employment
Opportunities
Family
Use of drugs and alcohol by parents, siblings, spouse
Family dysfunction (e.g., inconsistent discipline,
poor parenting skills, lack of positive family rituals
and routine)Family trauma (e.g., death, divorce)
GeneticInherited predisposition to alcohol or drug dependence
Alcoholic parent - 3 to 6 times higherAdult children of alcoholics have abnormal brain cortisol reactions to stressDrugs induce changes in genes (cocaine, FOS B)Behavioral
Aggressive behavior in childhoodConduct disorder; antisocial personality disorderAvoidance of responsibilities
Impulsivity and risk-takingAlienation and rebelliousness; reckless behaviorSchool-based academic or behavioral problems; school drop-out
Involvement with criminal justice system or illegal activitiesPoor interpersonal relationships
SocialAge of first useAlcohol- and drug-using peers
Low perception of harmSocial or cultural norms approving useExpectations about positive effects of drugs and alcohol
Availability of or accessibility to alcohol and drugs
Slide36REG FLAGS
Physical or sexual abuse
Parental substance abuse
Parental incarceration
Dysfunctional family relationships
Peer involvement with drugs or alcohol or
with serious crime
Smoking tobacco
Marked change in physical health
Deteriorating performance in school or job
Dramatic change in personality, dress, or friends
Involvement in serious delinquency or Crimes
HIV high-risk activities (e.g., injection drug use or sex with injection drug user)
Serious psychological problems (e.g., suicidal ideation or severe depression)
Slide37Neocortex (modern man)
Reasoning and learning
Consciousness
Motor and sensory
Memory
LanguageAbstract thoughtFlexible and plasticAble to execute both yes and noBoth on and off
Limbic and Reptilian (beast)
Survival
Emotions
Autonomic functions
Reward and appetite
Reliable and rigid
Only able to execute yes
Always on
NEOCORTEX
LIMBIC SYSTEM
REPTILIAN COMPLEX
Slide38Circuits Involved In Drug Abuse and Addiction
All of these brain regions must be considered in developing strategies to effectively treat addiction
Inhibitory/ Control
PFC
– prefrontal cortex
ACG
– anterior cingulate gyrus;
Motivation/ Drive
OFC
– orbitofrontal cortex
SCC
– subcallosal cortex
Reward/ Saliency
NAc
– nucleus accumbens
VP
– ventral pallidum;
Memory/ Learning
Hipp
– hippocampus;
Amyg
– amygdala
Slide39Natural Rewards and Dopamine Levels
Adapted from:
DiChiara
et at,
Neuroscience,
1999Adapted from Fiorino and Phillips, J Neuroscience, 1997
Slide40substantia nigra
locus coeruleus
Normal Pleasure Response
nucleus accumbens
VTR
Pleasure/Motivation Response
Increased Dopamine Release
YUM!!
Slide41substantia nigra
locus ceruleus
Brain Reward Pathway
Psychoactive Addictive Drugs Act on this Pathway
Slide42Brain Reward Pathway
substantia nigra
locus ceruleus
Wow!!!
Dopamine surge!!!
Drug
Slide43Brain Reward Pathway
substantia nigra
locus ceruleus
Wow!!!
Dopamine surge!!!
Drug
Dopamine, Serotonin, Norepinephrine…
Slide44Reward Pathway
The “Wow!!!” is a big reason people take drugs
but other things also happen…
Drugs act on the Brain Reward Pathway
Slide45Reward Pathway
Emotional & behavioral learning
Control of body movement
Early learning and memory processing
Attention states and automatic function
Areas
Slide46Continued Drug Use
substantia nigra
locus ceruleus
Wow!!!
A “
molecular
switch”
is thrown in the brain
Sensitization, Craving and Relapse
Loss of control over drug use
Compulsive drug seeking behavior
Slide47Neocortex (modern man) Hijacked!!
Euphoric memories
Profound changes in neurons and brain circuits
Impaired cognitive function
Adaptations in habit or non-conscious memory systems
Susceptibility to powerful emotional and environmental cues
Reptilian (beast)
Euphoric memories
Profound changes in neurons and brain circuits
Impaired cognitive function
Adaptations in habit or non-conscious memory systems
Susceptibility to powerful emotional and environmental cues
DRUG ADDICTION
HIJACKED BRAIN
Slide48The hijacked brain is trapped in a circle of
Dishonesty
Denial
Rationalizations
Justification
Minimization
Cravings
Guilt and Shame
LOSS of CONTROL
over taking a substance
Slide49Reasoning and learning
Consciousness
Motor and sensory
Memory
Language
Abstract thought
Flexible and plastic
Able to execute both yes and no
Both on and off
Survival
Emotions
Autonomic functions
Reward and appetite
Reliable and rigid
Only able to execute yes
Always on
Neocortex (modern man)
Limbic and Reptilian
Aberrant Dysfunctional Addiction Self –The Disease
Survival, distorted definition of survival
Hyper-reward, hyper-appetite
Manipulates Emotions
Autonomic functions
Hyper-rigid, hyper-reliable
Can access selective memories
Selectively accesses motor and sensory, for continued hyper-rewards
Unable to say no
Always on
Slide50Once born, the addiction self, is extremely durable and can affect a person after many years of abstinence, can be present for an entire lifetime
.
Eric Sprague
Slide51Effects of Drugs on Dopamine Levels
Adapted from:
DiChiara
and
Imperato
, Proceedings of the National Academy of Sciences USA, 1988, courtesy of NoraD Volkow, MD
Slide52Effects of Amphetamines on Dopamine Levels
Adapted from:
DiChiara
and
Imperato
, Proceedings of the National Academy of Sciences USA, 1988, courtesy of NoraD Volkow, MD
Slide53Long-term drug exposure impairs brain functioning
1. Release
2 to 10 times
more dopamine than natural rewards (eating, sex and social activities)
2.
Powerful reward strongly motivates people to take drugs again and again.3. The brain adjusts - producing less dopamine and reducing the number of receptors that can receive signals4. The ability to experience ANY pleasure is reduced.
Slide54Incentive Salience—
Wants/ Cravings
Incentive salience
is a type of motivation created in the brain because it has developed an association between a certain stimuli and reward. “I want and I want it now!!”
In the case of
addiction
this stimuli will be whatever drug the individual is using.
Incentive salience
is a far greater incentive than merely liking something.
Slide55Incentive Salience – Wants/ Cravings
Previously neutral stimuli are assigned
incentive salience
.
Smelling cigarette smoke can trigger a craving for nicotine
Drug paraphernalia now trigger drug craving.
Driving in or near a neighborhood where drugs were purchased triggers craving
Thus, if a person's addiction subsides and the individual subsequently encounters one of these secondary reinforcers, a craving for that drug may reappear.
Slide56Prolonged drug use changes
the brain in fundamental
and long-lasting ways
And evidence shows that these
changes are both
functional
and structural
.
Slide57DA D2 Receptor Availability
Control
Addicted
Cocaine
Alcohol
DA
DA
DA
DA
DA
DA
Reward Circuits
DA
DA
DA
DA
DA
Reward Circuits
DA
DA
DA
DA
DA
DA
Drug Abuser
Non-Drug Abuser
Heroin
Meth
Dopamine D2 Receptors are Lower in Addiction
DA
Slide58Slide59Safe Limits
ALCOHOL
Men: no more than 2 day, 14 week or 4 drink tolerance
Women and Men/Women over the age of 65: no more than 1 day, 7 week or 3 drink tolerance
Illicit Drugs: NO safe limit for use
All Tobacco products: NO safe limit for use
Prescription Drug misuse/abuse: NO safe limit for use
Slide60What is a “Standard Drink”
Slide61Slide62What should be treated first?
Modified from: Stahl, SM. Essential Psychopharmacology. Cambridge, UK: Cambridge University Press 2013.
Order of Treatment for Adults
Alcohol/ stimulant / substance abuse
(detoxification) /
nicotine
dependence
Eating Disorder—(
weight restoration/ stop behaviors)
Mood Disorders
Anxiety Disorders
(Trauma)
ADHD
Slide63Many of my patients just want a pill…..
Sorry, there are no magic pills.
Slide64Treatment Setting
Medical Detoxification and Stabilization/Inpatient hospitalization
Dual-diagnosis hospital inpatient
Free-standing Rehabilitation or Residential
Partial Hospitalization
Temporary recovery or halfway homes
Intensive outpatient
Outpatient DUI/DWAI/DUID programs
Slide65Multiple Therapeutic Approach
Neuro-Cognitive Behavioral Therapy
Contingency Management
Motivational Enhancement Therapy
Family Therapy (especially for youth)Individual and Group Psycho TherapyRecreational TherapyMusic TherapyEquine TherapyDisease Education ClassesSpiritual TherapyNutritional Therapy12 Step based programs
Slide66Medications for Recovery from Substances
Alcohol:
Naltrexone (
ReVia
)
Depot Naltrexone (Vivitrol)Acamprosate (Campral)Disulfiram (Antabuse)Opiates:Naltrexone(ReVia)Depot Naltrexone (Vivitrol)Buprenorphine (Subutex)Buprenorphine + Naloxone (Suboxone)
Methadone
Nicotine:
Varenicline (Chantix)
Buproprion (Wellbutrin/
Zyban
)
Nicotine-gum, patch, lozenge, inhaler
Slide67SUD Treatment – The ARS Approach
Stabilization
Inspiration
Motivation
Education
ApplicationInnovationContinuation
Slide68Stabilization = Detoxification and Initiating Treatment
Management of acute withdrawal
Craving Stabilization
Cessation of drug use
Continuing treatment at the appropriate level of care
Slide69Stabilization
-Detoxification
Sedative taper
Suboxone
Craving Control
Naltrexone Suboxone CBTPsychiatric Care Antidepressants Safe Anxiolytics
Mood Stabilizers
Antipsychotics
Safe insomnia medications
CBT
-Pain Control
NSAIDS
Membrane Stabilizers
SNRI’s
TCA’s Muscle relaxants Suboxone CBT
Slide70Inspiration
Inspiration
Belief
Change
Slide71Motivation
A Confrontational Process – we must confront the barriers to change
Develop a nurturing rapport with clients.
Induct clients to the partnership of the treatment process.
Explore what clients expect and determine discrepancies.
Prepare clients so that they know there may be some embarrassing, emotionally awkward, and uncomfortable moments Investigate and resolve barriers to treatment. Increase congruence between intrinsic and extrinsic motivation. Examine and interpret noncompliant behavior in the context of ambivalence and the disease and refocus on the treatment partnershipDemonstrate continuing personal concern
Slide72Education
A Teaching and Discovery Process
Disease
Themselves
Provide them a full tool box (coping skills, MAT,
etc) that they fully understandFamily
Slide73Application
A process of engagement and practice
Recovery Requires ACTION
Knowledge alone is not enough
Group therapy
Therapeutic communityFamily therapyPsycho DramaYogaMeditationMindfulness therapy
Slide74Innovation
Individualized treatment
Find something that works or create new programs
Internet
Smart phone Apps
Research
Slide75Continuation
Community Recovery
Transition programs to IOP care
Sober Living
Aftercare programs
Alumni GroupsVirtual therapy with AppsLong term goals and long term follow-up
Slide76Summary
Addiction is a chronic
DISEASE
Substance use is on the rise
Addiction is incredibly complex with multiple influencing factors
Addiction has significant effects on the brainTreatment is a lifelong process