Disease concept 041313 farley
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ARE ALCOHOLISM & DRUG ARE ALCOHOLISM & DRUG ADDICTION REALLY ADDICTION REALLY
DISEASES, AND IF SO, DISEASES, AND IF SO, SO WHAT ?SO WHAT ?
THE FARLEY CENTERTHE FARLEY CENTER04/13/1304/13/13
WILLIAMSBURG, VAWILLIAMSBURG, VA
LYNN LYNN HANKESHANKES, MD, FASAM, MD, FASAM
Clinical Professor EmeritusClinical Professor EmeritusClinical Professor EmeritusClinical Professor Emeritus
Department of PsychiatryDepartment of Psychiatry
and Behavioral Scienceand Behavioral Science
University of Washington University of Washington
School of MedicineSchool of Medicine
SeattleSeattle
ADDICTIONADDICTION
ALCOHOLISMALCOHOLISM
& ANY & ANY OTHEROTHER
DRUG DEPENDENCY DRUG DEPENDENCY ==
CHEMICAL DEPENDENCYCHEMICAL DEPENDENCY
CHEMICAL IS ADDICTIVE IFCHEMICAL IS ADDICTIVE IF
1. MIND ALTERING1. MIND ALTERING--MOOD CHANGINGMOOD CHANGING1. MIND ALTERING1. MIND ALTERING--MOOD CHANGINGMOOD CHANGING
2. REINFORCING2. REINFORCING
3. EUPHORIGENIC3. EUPHORIGENIC
NOT ADDICTIVENOT ADDICTIVE
�� ANTIDEPRESANTSANTIDEPRESANTS
�� LITHIUMLITHIUM
�� ANTIANTI--PSYCHOTICSPSYCHOTICS
CHEMICAL CLASSESCHEMICAL CLASSES
��OPIOIDSOPIOIDS
��SEDATIVESEDATIVE--HYPNOTICSHYPNOTICS
��STIMULANTSSTIMULANTS
��PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS
��CANNABINOIDSCANNABINOIDS
�� INHALANTSINHALANTS
ADDICTIVE POTENTIALADDICTIVE POTENTIAL
�� COCAINE/METHAMPHETAMINECOCAINE/METHAMPHETAMINE
�� SYNTHETIC OPIOIDS (FENTANYL)SYNTHETIC OPIOIDS (FENTANYL)
�� HEROINHEROIN�� HEROINHEROIN
�� MINOR OPIOIDSMINOR OPIOIDS
�� NICOTINENICOTINE
�� ALCOHOLALCOHOL
ADDICTIVE POTENTIALADDICTIVE POTENTIAL
�� OTHER SEDATIVESOTHER SEDATIVES
�� OTHER STIMULANTSOTHER STIMULANTS
�� PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS�� PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS
�� CANNABINOIDSCANNABINOIDS
�� CAFFEINECAFFEINE
U.S. MORTALITYU.S. MORTALITY
�� ILLEGAL DRUGSILLEGAL DRUGS
�� ALCOHOLALCOHOL
�� 10 PER DAY10 PER DAY
�� 400 PER DAY400 PER DAY�� ALCOHOLALCOHOL
�� ??
�� NICOTINENICOTINE
�� 400 PER DAY400 PER DAY
�� 1000 PER DAY1000 PER DAY
DEPENDENCYDEPENDENCY
�� Loss Of Loss Of CControlontrol
�� CCompulsive Useompulsive Use�� CCompulsive Useompulsive Use
�� Continued Use Despite Continued Use Despite Adverse Adverse CConsequencesonsequences
ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
�� IGNORANTIGNORANT
��STUPIDSTUPID
��CRAZYCRAZY
�� IMMORALIMMORAL
��WEAKWEAK
��SICKSICK
ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
IGNORANTIGNORANTIGNORANTIGNORANT
STUPIDSTUPIDEDUCATIONEDUCATION
ACTIVITYACTIVITY------PROBLEMSPROBLEMS
��CRAZYCRAZY ��PSYCHOPSYCHO--TXTX
ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
IMMORALIMMORAL CHURCH/JAILCHURCH/JAIL
ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
WEAKWEAK
WILLEDWILLED“JUST SAY NO“JUST SAY NO””
ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
SICKSICK TREATMENTTREATMENT
DISEASEDISEASE
A DYSFUNCTIONAL A DYSFUNCTIONAL A DYSFUNCTIONAL A DYSFUNCTIONAL STATE WITH STATE WITH CHARACTERISTIC CHARACTERISTIC FORMFORM
CHARACTERISTIC FORMCHARACTERISTIC FORM
��CAUSECAUSE
��SPECIFIC DEFECTSPECIFIC DEFECT
��SXSX--SIGNSSIGNS--LAB TESTSLAB TESTS��SXSX--SIGNSSIGNS--LAB TESTSLAB TESTS
��PREDICTABLE COURSEPREDICTABLE COURSE
��UNIFORM TREATMENTUNIFORM TREATMENT
��SIMILAR RESPONSESIMILAR RESPONSE
COMPARE DISEASESCOMPARE DISEASES
��DIABETESDIABETES
��AIDSAIDS��AIDSAIDS
��CHEMICAL CHEMICAL DEPENDENCYDEPENDENCY
DIABETESDIABETES
��CAUSECAUSE
��DEFECTDEFECT
��UNKNOWNUNKNOWN�� Insulin ImbalanceInsulin Imbalance
YESYES��SXSX--SIGNSSIGNS--LABLAB
��COURSECOURSE
��SAME TXSAME TX
��RESPONSERESPONSE
��YESYES
��YESYES
�� DietDiet--PillsPills--InsulinInsulin
��YESYES
AIDSAIDS
��CAUSECAUSE
��DEFECTDEFECT
��HIV +/HIV +/-- CoCo--FF
��T 4 CELLT 4 CELL
��SXSX--SIGNSSIGNS--LABLAB
��COURSECOURSE
��SAME TXSAME TX
��RESPONSERESPONSE
��YESYES
��YESYES
��UNKNOWNUNKNOWN
��N/AN/A
CHEMICAL DEPENDENCYCHEMICAL DEPENDENCY
��CAUSECAUSE
��DEFECTDEFECT
��UNKNOWNUNKNOWN�� CHEM/PSY IMBLNCECHEM/PSY IMBLNCE
YESYES��SXSX--SIGNSSIGNS--LABLAB
��COURSECOURSE
��SAME TXSAME TX
��RESPONSERESPONSE
��YESYES
��YESYES�� AAAA--OUT PTOUT PT--IN PTIN PT
��YESYES
“MEDICALIZE”“MEDICALIZE”-- IT’S A IT’S A DISEASE BECAUSE:DISEASE BECAUSE:
�� BEING SICK IS LESS SHAMEFUL THANBEING SICK IS LESS SHAMEFUL THAN
WILLFUL MISCONDUCTWILLFUL MISCONDUCTWILLFUL MISCONDUCTWILLFUL MISCONDUCT
�� THEN INSURANCE WILL PAY FOR TXTHEN INSURANCE WILL PAY FOR TX
�� HAVING AN ILLNESS ABSOLVES ONE HAVING AN ILLNESS ABSOLVES ONE
FROM SOCIAL RESPONSIBILITYFROM SOCIAL RESPONSIBILITY
DISEASE CHARACTERISTICSDISEASE CHARACTERISTICS
��CHRONICCHRONIC
��PRIMARYPRIMARY��PRIMARYPRIMARY
��PREDICTABLEPREDICTABLE
��“CATCHING”“CATCHING”
CHRONICITYCHRONICITYPERMANENTPERMANENT
NOT ALCOHOLNOT ALCOHOL--WASWAS--MM
BUT ALCOHOLBUT ALCOHOL--------ISIS--MM
PRONE TO RELAPSEPRONE TO RELAPSE
DIABETESDIABETES
CORONARY INSUFFICIENCYCORONARY INSUFFICIENCY
ALCOHOLISMALCOHOLISM
PRIMARYPRIMARY
�� PRIMARY: Stands alone independentlyPRIMARY: Stands alone independently
�� SECONDARY: To underlying primary ds.SECONDARY: To underlying primary ds.
NEUROSISNEUROSISNEUROSISNEUROSIS
PSYCHOSISPSYCHOSIS
PREDICTABLEPREDICTABLE
Often progressive in 4 Stages:Often progressive in 4 Stages:
EARLYEARLY---->>EARLYEARLY---->>
MIDDLEMIDDLE---->>
LATELATE---->>
TOO LATE +TOO LATE +
“CATCHING”“CATCHING”
THE ________ IS “CATCHING”THE ________ IS “CATCHING”
THE THE INSANITYINSANITY IS “CATCHING!”IS “CATCHING!”THE THE INSANITYINSANITY IS “CATCHING!”IS “CATCHING!”
The stress of living with an alcoholic The stress of living with an alcoholic produces dysfunctional coping behavior produces dysfunctional coping behavior similar to that in post traumatic stress similar to that in post traumatic stress syndrome !!syndrome !!
WHO ?WHO ?
EVERYONEEVERYONEEVERYONEEVERYONE
FROM “YALE TO JAIL”FROM “YALE TO JAIL”
QUESTION ?QUESTION ?
A. A. YOU’RE ALCOHOLICYOU’RE ALCOHOLIC
BECAUSE YOU DRINK TOO BECAUSE YOU DRINK TOO MUCHMUCHMUCHMUCH
B. B. YOU DRINK TOO MUCH YOU DRINK TOO MUCH BECAUSE YOU’RE BECAUSE YOU’RE ALCOHOLICALCOHOLIC
ANSWER !ANSWER !
B. YOU DRINK TOO B. YOU DRINK TOO B. YOU DRINK TOO B. YOU DRINK TOO MUCH BECAUSE MUCH BECAUSE YOU’RE ALCOHOLICYOU’RE ALCOHOLIC
OLD THEORYOLD THEORY
HEAVY DRINKINGHEAVY DRINKING------>>
ABUSEABUSE------>>
ALCOHOLISMALCOHOLISM
ALCOHOL ABUSEALCOHOL ABUSE
�� MEDICATE STRESSMEDICATE STRESS
�� MEDICATE MENTAL ILLNESSMEDICATE MENTAL ILLNESS
�� MOST TEENAGERSMOST TEENAGERS�� MOST TEENAGERSMOST TEENAGERS
�� MOST COLLEGE STUDENTSMOST COLLEGE STUDENTS
�� SOCIOPATHSSOCIOPATHS
NEW THEORYNEW THEORY
SOCIAL DRINKINGSOCIAL DRINKING
(NORMAL)(NORMAL)
ABUSEABUSE
(DISORDER)(DISORDER)
ALCOHOLISMALCOHOLISM
(DISEASE)(DISEASE)
NEW THEORYNEW THEORY
SOCIAL DRINKINGSOCIAL DRINKING
(CAN STOP)(CAN STOP)
ABUSEABUSE
(MIGHT STOP)(MIGHT STOP)
ALCOHOLISMALCOHOLISM
(CAN’T STOP)(CAN’T STOP)
DOUBLE MARTINI DOUBLE MARTINI TESTTEST
HEAVY DRINKERHEAVY DRINKER
ABUSERABUSER
ALCOHOLICALCOHOLIC
“…the addicted brain is, in fact, “…the addicted brain is, in fact, different in its neurobiology different in its neurobiology from the nonfrom the non--addicted brain.”addicted brain.”
Alan Leshner, Ph.D.Alan Leshner, Ph.D.
Director, NIDADirector, NIDA
DRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESS
www.drugabuse.gov
“ …a drug hijacks one’s brain, “ …a drug hijacks one’s brain, thereby hijacking one’s mind, and thereby hijacking one’s mind, and then one’s life.”then one’s life.”
Alan Leshner, Ph.D.Alan Leshner, Ph.D.
Director, NIDADirector, NIDA
BASIC BRAIN FUNCTIONBASIC BRAIN FUNCTION
�� All systems in balanceAll systems in balance
�� Chemical messengers:Chemical messengers:
––act fastact fast
––short durationshort duration
––small amountssmall amounts
ALCOHOL & DRUGSALCOHOL & DRUGS
�� Alter the balance of the systemAlter the balance of the system
�� Change the messengers:Change the messengers:
––slowed downslowed down
––prolonged actionprolonged action
––decreased responsedecreased response
www.drugabuse.gov
SPECT/PET SCANSSPECT/PET SCANS
�� ALTERS BRAIN BLOOD FLOWALTERS BRAIN BLOOD FLOW
––INCREASEDINCREASED to areas to areas ––INCREASEDINCREASED to areas to areas
required for drug userequired for drug use
–– decreaseddecreased to areas of thinking, to areas of thinking, learning, and memorylearning, and memory
controlcontrol on cocaineon cocaine
www.drugabuse.gov
SPECT / PET ScansSPECT / PET Scans
��Reduced brain glucoseReduced brain glucose
(70(70--80% of brain energy)80% of brain energy)(70(70--80% of brain energy)80% of brain energy)
��Decreased brain functionDecreased brain function
WHY LOSS OF CONTROL ?WHY LOSS OF CONTROL ?
�� ALTERED BLOOD FLOWALTERED BLOOD FLOW
�� ALTERED MESSENGERS & EFFECTSALTERED MESSENGERS & EFFECTS
�� DECREASED BRAIN GLUCOSEDECREASED BRAIN GLUCOSE�� DECREASED BRAIN GLUCOSEDECREASED BRAIN GLUCOSE
�� DECREASED BRAIN DOPAMINEDECREASED BRAIN DOPAMINE
�� CELLULAR CHANGE OR DAMAGECELLULAR CHANGE OR DAMAGE
SPECT / PET ScansSPECT / PET Scans
�� Cellular damageCellular damage
SO IT’S A DISEASE !SO IT’S A DISEASE !
SO WHAT ?SO WHAT ?SO WHAT ?SO WHAT ?
CHRONICITYCHRONICITYPERMANENTPERMANENT
NO RETURN TO SOCIAL DRINKINGNO RETURN TO SOCIAL DRINKING
NO RECREATIONAL DRUG USENO RECREATIONAL DRUG USE
PRONE TO RELAPSEPRONE TO RELAPSE
BUILD A DEFENSE VS. 1ST DRINKBUILD A DEFENSE VS. 1ST DRINK
RECOVERY REQUIRES MAINTENANCERECOVERY REQUIRES MAINTENANCE
“There exists, therefore, outside of “There exists, therefore, outside of alkaloids and habit, a sense for alkaloids and habit, a sense for
opium, an intangible habit which opium, an intangible habit which lives on, despite the recasting of the lives on, despite the recasting of the
organism. The dead drug leaves a organism. The dead drug leaves a ghost behind. At certain hours it ghost behind. At certain hours it ghost behind. At certain hours it ghost behind. At certain hours it
haunts the house.”haunts the house.”
JeanJean CocteauCocteau
French AuthorFrench Author18891889--19631963
“ We are unable, at certain times, to “ We are unable, at certain times, to bring into our consciousness with bring into our consciousness with sufficient force the memory of suffering sufficient force the memory of suffering and humiliation of even a week or a and humiliation of even a week or a month ago.” month ago.”
Alcoholics AnonymousAlcoholics Anonymous
AA World Services, IncAA World Services, Inc
New York, New York, 19391939
Childress, 1999Childress, 1999
MAINTAINENCEMAINTAINENCE
ALCOHOLICS ALCOHOLICS ALCOHOLICS ALCOHOLICS ANONYMOUSANONYMOUS
MAINTENANCEMAINTENANCE
ALCOHOLICS ANONYMOUSALCOHOLICS ANONYMOUSALCOHOLICS ANONYMOUSALCOHOLICS ANONYMOUS
AA is evidenced based, empirically
validated, and scientifically established
as the best form of maintenance
treatment to date!
PRIMARYPRIMARY
NO UNDERLYING DISEASE TO TXNO UNDERLYING DISEASE TO TX
TOTAL ABSTINENCE IS NECESSARYTOTAL ABSTINENCE IS NECESSARYTOTAL ABSTINENCE IS NECESSARYTOTAL ABSTINENCE IS NECESSARY
Willam Silkworth, MD:Willam Silkworth, MD:
“…the action of alcohol on these chronic “…the action of alcohol on these chronic alcoholics is a manifestation of an alcoholics is a manifestation of an allergyallergy.” (page xxviii).” (page xxviii)
Alcoholics AnonymousAlcoholics Anonymous
AA World Services, IncAA World Services, Inc
New York, New York, 19391939
ALLERGYALLERGY
�� TO PENICILLINTO PENICILLIN
�� TO MILKTO MILK�� TO MILKTO MILK
�� TO ALCOHOLTO ALCOHOL
Therefore, Therefore,
TOTAL ABSTINENCETOTAL ABSTINENCE
PATHOLOGYPATHOLOGY
TARGET ORGAN=BRAINTARGET ORGAN=BRAIN
DEFECT=CHEMICAL IMBALANCEDEFECT=CHEMICAL IMBALANCE
THEN: THEN: AVOIDAVOID THE CHEMICALTHE CHEMICAL
AVOIDANCE=AVOIDANCE=ABSTINENCEABSTINENCE
ABSTINENCE=TOTALABSTINENCE=TOTAL
TOTAL ABSTINENCETOTAL ABSTINENCE
AVOID ALL LIKE DRUGS:AVOID ALL LIKE DRUGS:
��BARBITURATESBARBITURATES
��NONNON--BARBITURATE SEDATIVESBARBITURATE SEDATIVES
��BENZODIAZEPINESBENZODIAZEPINES
––ANXIOLYTICSANXIOLYTICS
––HYPNOTICSHYPNOTICS
TOTAL ABSTINENCETOTAL ABSTINENCE
AVOID ALL ADDICTIVE DRUGS:AVOID ALL ADDICTIVE DRUGS:
�� OPIOIDSOPIOIDS
�� STIMULANTSSTIMULANTS
�� PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS
�� CANNABINOIDSCANNABINOIDS
�� INHALANTSINHALANTS
TOTAL ABSTINENCETOTAL ABSTINENCE
CAUTION OTHER DRUGS:CAUTION OTHER DRUGS:
�� OTC DECONGESTANTSOTC DECONGESTANTS
�� OTC ANTIHISTAMINESOTC ANTIHISTAMINES�� OTC ANTIHISTAMINESOTC ANTIHISTAMINES
�� STEROIDSSTEROIDS
�� MUSCLE RELAXANTSMUSCLE RELAXANTS
��“NON“NON--ADDICTIVE” ANALGESICSADDICTIVE” ANALGESICS
��“NON“NON--ADDICTIVE” SEDATIVESADDICTIVE” SEDATIVES
PREDICTABLEPREDICTABLE
ONLY 3 OPTIONS:ONLY 3 OPTIONS:
LOCKED UPLOCKED UP
COVERED UPCOVERED UP
SOBER UPSOBER UP
“CATCHING”“CATCHING”
ADDICTION IS A FAMILY AFFLICTIONADDICTION IS A FAMILY AFFLICTION
THEREFORE: TX THE FAMILY AS WELL !THEREFORE: TX THE FAMILY AS WELL !
SPOUSE/ S OSPOUSE/ S O
�� COCO--DEPENDENCY TREATMENTDEPENDENCY TREATMENT�� COCO--DEPENDENCY TREATMENTDEPENDENCY TREATMENT
�� ALAL--ANONANON
CHILDRENCHILDREN
�� FAMILY THERAPYFAMILY THERAPY
�� ACOA (Adult Children Of Alcoholics)ACOA (Adult Children Of Alcoholics)�� ACOA (Adult Children Of Alcoholics)ACOA (Adult Children Of Alcoholics)
�� ALAALA--TEENTEEN
�� ALAALA--TOTTOT
ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
�� IGNORANTIGNORANT
��STUPIDSTUPID
��CRAZYCRAZY
�� IMMORALIMMORAL
��WEAKWEAK
��SICKSICK
THEREFORE, ADDRESSTHEREFORE, ADDRESS
�� NOT NOT MORALLYMORALLY
�� BUT BUT MEDICALLYMEDICALLY�� BUT BUT MEDICALLYMEDICALLY
�� WITH:WITH:
––DIGNITYDIGNITY
––PRIVACYPRIVACY
––CONFIDENTIALITYCONFIDENTIALITY
REFERENCEREFERENCELewis, DC: A Disease Model of Lewis, DC: A Disease Model of
Addiction. In NS Miller & MC Addiction. In NS Miller & MC Doot (eds.) Doot (eds.) Principles of Principles of Addiction Medicine Addiction Medicine (1994). (1994). Addiction Medicine Addiction Medicine (1994). (1994). Chevy Chase, Maryland, Chevy Chase, Maryland, American Society of Addiction American Society of Addiction Medicine, section 1, Chapter 7, Medicine, section 1, Chapter 7, pages 1pages 1--8.8.
THE “MESSAGE”THE “MESSAGE”
�� C D=ALCOHOLISM & ANY C D=ALCOHOLISM & ANY OTHER OTHER DDDD
�� C D=A DISEASE STATEC D=A DISEASE STATE
�� NO ONE IS IMMUNENO ONE IS IMMUNE�� NO ONE IS IMMUNENO ONE IS IMMUNE
�� DENIAL=CHIEF SXDENIAL=CHIEF SX----MAJOR OBSTACLEMAJOR OBSTACLE
�� INTERVENTION IS NECESSARYINTERVENTION IS NECESSARY
THE “THE “MESSAGEMESSAGE””
�� TX = BIOTX = BIO--PSYCHOPSYCHO--SPIRITUALSPIRITUAL
�� AA/NA IS ESSENTIALAA/NA IS ESSENTIAL
MONITORING IS CRITICALMONITORING IS CRITICAL�� MONITORING IS CRITICALMONITORING IS CRITICAL
�� TX WORKS W/UNALTERED RXTX WORKS W/UNALTERED RX
�� REHABILITATEREHABILITATE
�� DON’T TERMINATEDON’T TERMINATE