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A New Paradigm for RecoveryUniversity of Florida

Scott Teitelbaum, M.D. FASAM, FAAP, Vice Chairman & Chief of Addiction Medicine

ASAM 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.

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.

Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV

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0.80.8

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1.21.2

1.41.4

1.61.6

1.81.8

55 1010 1515 2020 2525 3030 3535 4040 4545 5050 5555 6060 6565

THCTHCALCOHOLALCOHOL

TOBACCOTOBACCO

7070 7575

National Epidemiologic Survey on Alcohol and Related Conditions, 2003

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Addiction is a Developmental Disease

Gateway Drug

Statistics Those aged 18-25 most likely to use illicit

drugs. Age at which an adolescent begins to use

alcohol is a predictor of later alcohol and drug problems, particularly if first use is before age 15.

60 % of persons aged 18-25 have tried an illicit drug before

34% have tried an illicit drug in the past year 20% have tried an illicit drug in the past month

National Household Survey on Drug Abuse, 2005

Winter, 2013: SAMHSA

Between 2010 & 2011, non-medical use of prescription drugs declined among young adults ages 18-25 (from 2M to 1.7M; 14%)

Success of national efforts to address prescription drug problem

BUT… marijuana and heroin use increased

Access predicting introduction to use

As to obtaining prescription opiates, >50% of 12th graders were “given the drugs or bought them from a friend or relative”

Despite age group’s internet facility, number purchasing opioids on internet was negligible

Inherent trust of prescribed drugs

Less harmful because medically administered

Dosage regulated by medical profession and governmental oversight

Purity of substance and quality control

Might Not Meet Today’s FDA Standards

Young adults commonly transitioning from prescription opioids to heroin Availability of heroin + scarcity of Rx opiates Price of heroin

2010 to 2011, heroin overdose deaths increased 47% in one year (2,789 to 4,102) across entire age spectrum of U.S. population

36 % of those aged 19-28 report having consumed more than 5 drinks in a row in the preceding 2 weeks

Hippocampal volumes were found to be significantly smaller in those youths with an Alcohol Use Disorder

Smaller hippocampal volumes with longer-duration AUD

May effect brain structures critical to learning and memory formation

National Institute on Alcohol Abuse and Alcoholism

Generation Rx

18% of teens have abused Vicodin 20% tried Ritalin or Adderall without Rx 9% abused OTC cough syrup to get high More teens had abused a prescription

painkiller in 2004 than Ecstasy, cocaine, crack or LSD

April 21, 2005. Partnership for a Drug Free America. 17th annual study of teen drug abuse.

Designer Drugs:

What’s New & Ongoing

GG

Special KSpecial K

SpeedSpeed

Crystal

Crystal

DMTDMT

BZPBZP

“Its All About Sensation”

Smell sensation is intensified by the high, resulting in a pleasurable effect from the fumes

Vicks inhalants, cough drops, surgical masks with med rub

Serotonin rush

Neurotoxicity of DrugsNeurotoxicity of Drugs

substantia nigra substantia nigra

locus ceruleus locus ceruleus

What’s happening at the cellular level?

What’s happening at the cellular level?

Designer Cannabinoids

This raising suspicion that these products may contain unknown chemicals that produce effects similar to cannabinoids In Dec. 2008 a synthetic cannabinoid JWH-018

was discovered in the herbal smoking blend Spice®

Other synthetic cannabinoids: HU-210, HU-211, and JWH-073 were also discovered and are likely responsible for the psychoactive effects in these products

Designer Cannabinoids

Synthetic cannabinoids can produce the same or even more powerful effects as those produced by the cannabinoid molecules in the marijuana plant

They also have very different molecular structures than the plant cannabinoids

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Nov. 4, 2002

Marijuana Perceived Marijuana Perceived Risk vs. UseRisk vs. Use

Adolescents with AUD still appeared to have reduced neuropsychological functioning after 3 weeks of abstinence

“Arrested Development”

Normal risk-taking behaviors magnified with the addition of a substance

Pre-frontal cortex (responsible for logical thought, judgment, decision making) not fully formed until mid- 20’s. Substance use can impair healthy brain development

Emotional coping skills often delayed as a result of substance use

Healthy Heart

Decreased Heart Decreased Heart MetabolismMetabolism in in Heart Disease PatientHeart Disease PatientDecreased Heart Decreased Heart MetabolismMetabolism in in Heart Disease PatientHeart Disease Patient

ADDICTION IS A DISEASE OF THE BRAIN Like other diseases, it affects tissue function

Control Cocaine Abuser

Decreased Brain Metabolism in Drug Abuse Patient

Sources: From the laboratories of Drs. N. Volkow and H. SchelbertSources: From the laboratories of Drs. N. Volkow and H. Schelbert

High

Low

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Hypofrontality in Cocaine Dependent Hypofrontality in Cocaine Dependent PatientsPatients

Reduced Metabolic activity at baseline in cocaine dependent subjects

Drugs Attack the Prefrontal Cortex & Dependence Consequences are related to dysfunctions in the Prefrontal Cortex

Unfortunately the Prefrontal Cortex is Critical for : Decision-making Weighing of risks vs. rewards Assigning emotional valence to stimuli Suppressing limbic impulses Goal-directed behaviors

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The Memory of DrugsThe Memory of Drugs

Nature VideoNature Video Cocaine VideoCocaine Video

Front of Front of BrainBrain

Back Back of of

BrainBrain

AmygdalaAmygdalanot lit upnot lit up

AmygdalaAmygdalaactivatedactivated

Brain areas where volumes are smaller in adolescents

than young adults

During Adolescence the COGNITION-EMOTION

Connection is Still Forming

During Adolescence the COGNITION-EMOTION

Connection is Still Forming

Amygdalo-cortical SproutingContinues Into Early Adulthood

Amygdalo-cortical SproutingContinues Into Early Adulthood

Childhood Adolescence Adult

Sowell, E.R. et al., Nature Neuroscience, 2(10), pp. 859-861, 1999. Cunningham, M. et al., J Comp Neurol 453, pp. 116-130, 2002.

The Adolescent Brain is Still Developing

Adolescent Brain

These brain changes are relevant to adolescent behavior Prefrontal cortex (PFC) is pruned and not fully

developed until mid-20’s Amygdala (and n.a.) show less pruning and

tend to dominate the PFC

Adolescent Brain Changes

These brain changes are relevant to adolescent behaviorPrefrontal cortex (PFC) is

pruned; not fully developed until mid-20’s

Amygdala (and n.a.) show less pruning and tend to dominate the PFC

judgment

rewardsystem

amygdala

nucleusaccumbens

prefrontalcortex

Ken Winters, Ph.D.

Judgment vs. Reward

Amygdala = Reward System

Prefrontal Cortex =Judgment

Nucleus Accumben

s

Ken Winters, Ph.D.

Adolescent Brain

This imbalance leads to... planned thinking

impulsiveness self-control risk-takingPFC

amygdala

I like to use drugs!

Ken Winters, Ph.D.

Drugs are

bad!

From “Oops” to Dependence

Ken Winters, Ph.D.

“Oops Phenomenon”

First use to “FEEL GOOD”

Some continue to compulsively use because of the reinforcing effects (e.g., to “FEEL NORMAL”)

Changes occur in the “reward system” that promote continued use

Ken Winters, Ph.D.

Reward System

The reward system is responsible for seeking natural rewards that have survival value seeking food, water,

sex, and nurturing Dopamine is this

system’s primary neurotransmitter

Ken Winters, Ph.D.

Addiction Liability

~10% who ever use marijuana become daily users

Conditional dependence – risk of dependence of those who ever use substance Marijuana 9% Ethanol 15% Cocaine 17% Heroin 23% Tobacco 32%

Age of Onset of First Alcoholic Symptoms Among Alcoholics

Age (years) %

10 – 14 3

15 – 19 39

20 – 24 22

25 – 30 15

30 – 34 5

35 – 40 4

Natural History of Primary Alcoholism

Years

Age at first drink 12-14

Age at first intoxication 14-18

Age at first minor problem 18-25

Usual age of onset 23-33

Usual age of treatment entry 40

Usual age of death* 55-60* Leading cause: Heart or liver disease, Cancer, Accidents, Suicide

Socio-culturalSocio-cultural

EnvironmentalEnvironmentalPsychologicalPsychological

Influences susceptibility Influences susceptibility to drug usageto drug usage

The processes The processes that initiate and that initiate and maintain maintain alcoholism are alcoholism are regulated by regulated by interactions interactions among nerve among nerve cells in the braincells in the brain.

BiologicalBiological

42NIH/NIDA

Cannabis Abuse and the Adolescent Brain

Epidemiology

• Marijuana is the most widely used illicit drug both in the U.S. & world-wide

• More than 75 million (over 34%) of Americans 12 years or older have tried it at least once & almost 19 million have used it in the past year

• Average age of 1st use has been declining:- 12-17 year olds – 13.6 years

- 18-25 year olds – 16 years

• While most discontinue marijuana by their mid-20’s, a subset maintain daily, long-term use

Marijuana- Potency D.E.A. Seizure Data

Marijuana- Chronic Effects

Behavioral- “Amotivational syndrome” Cognitive- impaired memory/attention Psychiatric- rare but real permanent psychosis

(likely “flips” those predisposed) Respiratory- cancer, COPD Cardiovascular- HTN, tachycardia, MI Decreased Immunity Teratogenicity- unknown extent of fetal

neurotoxicity Reproductive- decreased testosterone, sperm

count/motility; inhibits prolactin, LH, GH

Medical Utility of Marijuana

Some efficacy shown in many areas However no studies are available comparing

marijuana to best known available treatments

Also, smoking as a delivery mode is undesirable because of toxicity and variability in dosing

CANNABIS AND THE BRAIN

Increased risk of schizophrenia

Reduced Thalamus size

Decreased IQ

Decreased efficiency of executive function

Hyperactive reward centers

Relation Between Marijuana & other Drug Use

• Early age of onset is a major predictor both of continued frequent marijuana use & of likelihood of using other drugs (Denenhardt, et al. 2001, Lynsky, et al. 2003)

• The increased potency of marijuana may make the brain less responsive to endogenous cannabinoids. This may be especially marked in the still developing adolescent brain

• Combination of earlier onset & stronger marijuana may increase anxiety & apathy in teens & make other drug use more attractive

• Twin studies found early marijuana users had increased rates of other drug use and problems later on; odds of other drug use ranged from 2.1-5.2 times higher

Cannabis – most prevalent illicit drug identified in impaired drivers

Risk of involvement in a motor vehicle accident (MVA) increases 2-fold after cannabis smoking.

Cannabis smoking increases lane weaving and impaired cognitive function.

Critical-tracking tests, reaction times, divided-attention tasks, and lane position variability all show cannabis-induced impairment.

Combining cannabis with alcohol enhances impairment, especially lane weaving.

Hartman RL, Huestis MA. Cannabis Effects on Driving Skills. 2013; 59(3): 478-492.

Marijuana Use Linked with Increased Risk of Motor Vehicle Crashes

Greater the amount of marijuana in a person’s urine, the greater the risk of a car crash

28% of drivers who died in an accident tested positive for non-alcohol drugs (most commonly, marijuana)

Marijuana use by drivers is associated with a significantly increased risk of being in a motor vehicle crash.

Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana Use and Motor Vehicle Crashes. Epidemiologic Reviews. Advance Access published October 4, 2011.

Users typically start in late teens Use peaks in 20’s Use dramatically declines with association of

starting families and careers

10% will become daily users 20-30% will become weekly users

USER PROFILE

Challenges: YA score higher on pre-contemplation, lower

on contemplation, determination, action, motivation and readiness for change than older adults

Higher rates of treatment non-compliance and positive drug-test at discharge

American Journal of Drug and Alcohol Abuse, 2003

Treatment of Young Adults

Focus on the treatment readiness Work on development of healthier coping skills Work on improving interpersonal relationships Treatment of underlying psychiatric conditions

(common in early use of substances) Family therapy essential to challenge familial

patterns and educate loved ones

Approaches to Treatment of the Young Adult

Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses

Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses

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4040

5050

6060

7070

8080

9090

100100

Drug DependenceDrug Dependence

Type I DiabetesType I Diabetes

HypertensionHypertensionAsthmaAsthma

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to 6

0%

40

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0%

30

to 5

0%

30

to 5

0%

50

to 7

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0%

50

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0%

50

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0%

Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

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Does Work

Treatment Today

Only 1 in 10 Americans who need treatment receive it

Of those that need it, approximately 95% don’t think they do

Of the 5% who believe they need it, 2/3 made no effort to obtain it

Less than 50% of those admitted to publically funded treatment successfully completed treatment

Acute Care Treatment as a Revolving Door

Of those admitted to the U.S. public treatment system in 2003, 64% were re-entering treatment including 23% accessing treatment the second time, 22% for the third or fourth time, and 19% for the fifth or more time (OAS/SAMHSA, 2005).

The Prevailing Acute Care Model

An encapsulated set of specialized service activities (assess, admit, treat, discharge, terminate the service relationship).

A professional expert drives the process. Services transpire over a short (and ever-shorter)

period of time. Individual/family/community is given impression at

discharge (“graduation”) that recovery is now self-sustainable without ongoing professional assistance (White & McLellan McLellan, in press).

Treatment (Acute Care Model) Works!

Post-Tx remissions one one-third, AOD use decreases by 87% following Tx, &, substance substance-related problems decrease by 60% following Tx (Miller, et al, 2001).

Lives of individuals and families transformed by addiction treatment.

Treatment Works, BUT…

POST-TREATMENT RELAPSE The majority of people completing addiction

treatment resume AOD use in the year following treatment (Wilbourne & Miller, 2002).

Of those who consume alcohol and other drugs following discharge from addiction treatment, 80% do so within 90 days of discharge (Hubbard, Flynn, Craddock, & Fletcher, 2001).

Treatment Works, BUT …

LOW ATTRACTIONOnly 10% of those needing treatment received

it in 2002 (SAMHSA, 2003) & access compromised by waiting lists (Donovan, et al, 2001).

HIGH ATTRITIONMore than half of clients admitted to addiction treatment do not successfully complete

treatment

Treatment Works, BUT…

LOW SERVICE DOSEInadequate doses of Tx contribute to risk of

relapse & future readmissions LACK OF CONTINUING CARE

Only 1 in 5 adult clients participated in continuing care (McKay, 2001) and only 36% of adolescents received any continuing care (Godley, Godley & Dennis, 2001)

Fragility of Early Recovery

Most individuals leaving addiction treatment are fragilely balanced between recovery and re-addiction in the hours, days, weeks, months, and years following discharge.

Recovery and re-addiction decisions are being made at a time that service professionals have disengaged from their lives, while many sources of recovery sabotage are present.

Similarities to Other Medical Disorders

Substance addiction comparable to asthma, hypertension and diabetes.

Risk of relapse highest during first 3-6 months. Length of time in treatment is key Patients respond best to a combination of self

help and behavioral interventions. Treatment of severe cases & dual disorders

requires experts but, improves outcomes

Phase I: What are Physician Health Programs (PHP)?

Not treatment, disciplinary, law enforcement or licensing organizations

Active care managers overseeing long-term care including drug testing They select and communicate with caregivers

including treatment programs, monitoring organizations and doctors/therapists/counselors

Physicians who enter PHP care face serious consequences for any noncompliance including any alcohol or drug use

PHP Long-Term Drug Test Results

Over the course of 5 years: 78% of all physicians

had zero positive drug tests

14% had only 1 positive drug test

3% had only 2 positive drug tests

5% had 3 or more

Lessons from the PHPS

1) Zero tolerance for any use of alcohol and other drugs2) Thorough evaluation and patient-focused (rather

than program-focused) care3) Prolonged, frequent random testing for both alcohol

and other drugs4) Effective use of leverage5) Defining and managing relapses: swift, certain and

meaningful consequences for any substance use and noncompliance

6) Goal of lifelong recovery rooted in the 12-Step fellowships

The New HIGHER Standard

The new paradigm has been successfully used in the criminal justice system – a population entirely different than physicians

New Paradigm in the CJS

Hawaii’s Opportunity Probation with Enforcement (HOPE) and South Dakota’s 24/7 Sobriety Project

These programs uphold the zero tolerance standard through drug tests and immediate, brief, incarceration for any drug use

Treatment is available on offender request but only required for individuals who demonstrate the need, using “Behavioral Triage”

12-Step participation is optional but encouraged

HOPE Drug Test Results

Over the course of one year: 61% of all HOPE

participants never had a single positive drug test

20% had only 1 9% had 2 10% had 3+

(Hawken & Kleiman, 2009)

24/7 Sobriety Drug Test Results

Over the average 111 days of participation: 55% never fail a test 17% fail only 1 time 12% fail only 2 times 16% fail three 3+

times

Summary of Findings

Zero tolerance with swift, certain, and meaningful consequences for any use of alcohol and other drugs – contrary to reasonable assumptions – leads to lower rates of use, higher rates of long-term success, and lower rates of failure

PHPs produced impressive results previously unseenHOPE and 24/7 Sobriety programs produced lower

rates of new crimes and lower rates of incarcerationUse of new concept of “Behavioral Triage” –

treatment is reserved for those who need it to stay clean and sober and for those who choose it

How Are These Programs Different?

Old Paradigm of care management: Infrequent or no testing; when testing occurs in

treatment, it is scheduled Responses are long-delayed and unpredictable – to

missed visits, missed tests, and positive tests Virtually all treatment is short-term (30 days, a few

months, or maybe a year) while the substance use disorders last for lifetimes

The 12-Step programs are underused or not used at all in many current treatment programs

Effective substance treatment

Typically incorporates many components, each directed at a particular aspect of the illness

Must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society

Need NOT be voluntary to be effective!

Wisdom of involuntary treatment order

21% of Americans ages 18-25 have substance use disorder to severity requiring treatment 96% of these addicted individuals do not

perceive the need for assistance

**Courts provide critical access to care

What is recovery? A working definition from the Betty Ford

InstituteThere is an unknown but very large number of individuals who have experienced and successfully resolved dependence on alcohol or other drugs. These individuals refer to their new sober and productive lifestyle as “recovery.” Although widely used, the lack of a standard definition for this term has hindered public understanding and research on the topic that might foster more and better recovery-oriented interventions.

To this end, a group of interested researchers, treatment providers, recovery advocates, and policymakers was convened by the Betty Ford Institute to develop an initial definition of recovery as a starting point for better communication, research, and public understanding.

Recovery is defined in this article as a voluntarily maintained lifestyle composed characterized by sobriety, personal health, and citizenship. This article presents the operational definitions, rationales, and research implications for each of the three elements of this definition.

The Betty Ford Institute Consensus Panel

Journal of Substance Abuse Treatment 2007; 33: 221-228.

The Betty Ford Institute Consensus Pane (Dr Gold was a member of this panel )Journal of Substance Abuse Treatment , 2007; 33:221-228.

Recovery = a voluntarily maintained lifestyle characterized by:Sobriety

Early (1-11 months) Sustained (1-5 years) Stable (> 5 years)

Personal health Physical Mental Social Spiritual

Citizenship “Giving-back” Quality of life

While science has taught us that addiction is a hijacking of the brain, recovery must involve healing of the heart

and the soul.

Drug Use Addiction TreatmentNormal

Recovery

The Great ChallengeFor Addiction Treatment in 21st

Century

To Integrate:

Addiction Medicine, Psychiatry and Spirituality in the Treatment of

Substance Use Disorders.

Challenges

Increasing Rx misuse Younger age of onset of use More MJ smoking youth Poly Drug, alcohol users teens Dual Disorders MDs role in Rx misuse Aging Floridians and Addictions Health Providers-MDs role in failure to Dx ED-ERs role in failure to DX and intervene