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Addiction SOS Colleague Family Member Friend Secrecy & Shame Stepping Out of the Shadows Tony Tommasello, PD, PhD PEAC Maryland, Executive, Director MPhA Conference -Ocean City June 7, 2013 At the end of session, participants should be better able to: 1. Explain that drug addiction can be a fatal chronic condition requiring medical treatment LEARNING OBJECTIVES 2. Identify early indicators of substance abuse 3. Express the positive benefits and success of effective medical treatment 4. Communicate effectively to those with substance use disorders that treatment is preferable to continued suffering ADDICTION: VIDEO: Hillbilly Heroin, CurrentTV ADDICTION: What is it? Addiction is a Disease Cancer Diabetes Heart Disease ADDICTION Addiction is a Brain Disease Prolonged Use Changes the Brain in Fundamental and Lasting Ways “Healthy” Brain “Cocaine Addict” Brain Addiction is a Brain Disease and It Matters. Allan Leshner: Science 278(5335), 45-47, 1997. Repeated pharmacological stimulation of the reward system trains the brain to the drug experience. Compared to a “normal” brain the addicted brain: reacts uniquely to “triggers” expresses “anticipatory” neuro-activation may be less responsive to a natural stimulus Aspects of Addiction Chronic Primary Progressive Relapsing Fatal Incurable but manageable Not relieved by treating a suspected causative condition Gets worse if untreated Prone to re-occurrence if untreated Premature death in untreated individuals ADDICTION: How Does It Work? Healthy Brain – Wired for Pleasure but Why? Natural Rewards Food Sex Excitement Comfort Good for you. Good for the species. Do that again. Reward Circuit Activation Events related to the good feeling are cognitively experienced and paired to it (Pavlov’s dogs) Anticipatory cascade initiated when a component of the behavior occurs (persons, places, events, emotions). Activation of Reward Acute Reinforcing Effects Intravenous Self-Administration Drug Ethanol Cocaine Heroin Diazepam Nicotine PCP THC Ibuprofen Aspirin Paroxetine Venlafaxine Clozapine Lithium Memantine Self-Administered YES YES YES YES YES YES YES NO NO NO NO NO NO NO Short – Run Comparison DRUG HIGHS NATURAL HIGHS No practice needed Start-up costs are high Strong effects initially practice Low-cost start-up (time and money) equipment Easy to obtain Social bonding Limited by beliefs Mankind’s best kept secret Long – Run Comparison Drug Highs: Natural Highs High maintenance costs (tolerance ) Intrinsic vs. external origin Unpredictable effects (street market) “It’s the real thing” Toxicity and side effects Low maintenance costs Risks, guilt, and losses Skill improves with practice The drug, not the individual, is in control Trains the brain to drugs Artificial stimulus Risks are defined, managed, and minimized Transferable skills The individual is in control Protected by natural constraints ADDICTION: Dependencies Indicators of Psychological Dependence 1. Concern about drug supply 2. Stockpiling drugs 3. Carrying or “holding’ drugs 4. Taking risks in order to use drugs 5. Using drugs alone 6. Changing friends 7. Finding excuses to use drugs 8. Becoming defensive Opioid Dependence IS What Is Opioid Dependence? • A chronic medical condition affecting the brain • Manageable, like other chronic diseases Opioid Dependence Is NOT • A moral failing • A sign of personal weakness • Requires long-term treatment to avoid relapses • Responds to treatment 21 DSM-5 revisions 1. Tolerance 2. Withdrawal 3. More use than intended 4. Craving for the substance 5. Unsuccessful efforts to cut down 6. Spend excessive time in acquisition 7. Activities given up 8. Failure to fulfill major role obligations 9. Use despite consequences 10. Recurrent use in hazardous conditions 11. Continued use despite consistent social or interpersonal problems “Substance Use Disorder”: 2-3 mild 4-6 moderate 7-11 severe ADDICTION: Is it a Choice? Addiction Defined Addiction = Compulsive use, with loss of control and continued use despite problems. Elements of Compulsivity: Constant thoughts of drug acquisition Anticipation of opportunities to use Defer other priorities of life Unable to resist desire to use “Every morning I woke up with the thought that I needed to make $300 today” Aspects of Loss of Control Inability to use in moderation consistently Easier to abstain completely Frequent episodes of excessive use Continued Use Despite Problems Loss associated with use Multiple crisis not seen as drug-related Sincere promises to self and others to quit No decision to seek treatment ADDICTION: Management First priority is drug acquisition and use Addiction Behaviors Negative consequences occur in order 1) Interpersonal relationships suffer 2) Productivity declines 3) Self-Esteem plummets 4) Health problems emerge or worsen Note: Legal problems can occur at any time. EXAMPLES OF RISK AND PROTECTIVE FACTORS Risk Factors Domain Protective Factors Early Aggressive Behavior Individual Self-Control Poor Social Skills Individual Positive Relationships Lack of Parental Supervision Family Parental Monitoring and Support Substance Abuse Peer Academic Competence Drug Availability School Anti-Drug Use Policies Poverty Community Strong Neighborhood Attachment From NIDA: The Science of Drug Abuse and Addiction URL: http://www.nida.nih.gov/scienceofaddiction/addiction.html Reduce or Control Symptoms Goals of Chronic Disease Management Prevent or Slow Progression Sustain or Improve Quality of Life Promote Treatment Engagement Motivate Patient to Internalize the Locus of Control Strive for Medication Adherence Even During Asymptomatic Periods Stages of Change Change is hard and not immediate Patience Self control needed Change Occurs in Stages Pre-comtemplation Not thinking change is needed or desired Contemplation Change may help but not needed now Preparation Ready to begin change in next 30 days Action Taking the first step Maintenance Behavioral change secured and stabilized ADDICTION: Treatment Why Treatment ? Rewards Negative consequences Utility Theory Dysfunctional lifestyle of opioid addiction makes treatment a desired alternative Medications approved for opioid addiction treatment include oral methodone, buprenorphine/naloxone sublingual tablets and film and naltrexone tablets and epot injections Primary Treatments are Non-Pharmacological 1. Abstinence from illicit and non-prescribed mood altering drugs 2. Individual and/or group cognitive behavioral therapy 3. Urine monitoring for drugs of abuse (also sweat, saliva, and blood) 4. Support group participation Narcotics anonymous Alcoholics anonymous Patient Response to Treatment Varies Patient characteristics – age, employment experiences, concurrent illnesses, family support. Patient history – duration and level of drug use Past treatment experiences (stepped care) Patient motivation Length of time in treatment Acknowledge & address the presenting crisis Family, employment, legal, medical Achieve abstinence from drugs of abuse Order of treatment priorities Medical withdrawal or opioid maintenance Evolve abstinence into sobriety Replace the struggle to abstain with a desire to remain drug free. Establish recovery as a life priority Internalize the locus of control Brutal honesty Landmark events in recovery 1. Achieving abstinence 2. Reacquiring one’s sense of responsibility 3. Reconnecting with a broadening range of emotions 4. Re-establishing intimacy in one’s relationships (parents, siblings, friends) 5. Being discriminating in selecting and establishing new social connections Coercion (leading a horse to water) Coerced treatment can be effective. Court-Ordered Probation Family Pressure Employer Sanctions Medical Consequences Licensing Authorities “Tie the horse to the trough and when he gets thirsty he’ll drink” (Father Martin of Ashley) ADDICTION: Stepping out of the Shadows Stepping out of the Shadows Addiction is a chronic medical condition affecting the brain Pharmacotherapy combined with behavioral interventions are effective treatments Treatment effectiveness is comparable other chronic diseases Stepping out of the Shadows The educational need in the addiction area is massive From health professionals to the general population there is little understanding of the science of addiction and recent clinical advances in its treatment. Stepping out of the Shadows The secret and seductive nature of this disease obscure its progression, lead to denial in both the addicted individual and his/her family, foster continued deterioration until an egregious complication occurs (arrest, job loss, ER admission or other dramatic physical distress), and culminates in a crisis at which point someone reaches out for help. Stepping out of the Shadows PEAC is committed to removing the stigma of addiction and placing it in a medical context, identifying its signs and symptoms particularly those in the early stage of illness, and describing its treatment and recovery potential in order to increase treatment demand early in the course of illness. ADDICTION: Where Do I Go? Community Resources www.PEACMaryland.org Addiction SOS Stepping Out of the Shadows
