Addiction Myths and

Science

David Kan, MDSan Francisco, Department of

Veteran Affairs

Overview

Understand the science of addiction and its relationship to other medical diseases

Understand the concepts of relapse and recovery

Describe disease-specific treatment of addiction including medication assisted treatment

Myths of Addiction Treatment

Myth of Self-Medication Treating “underlying” disorders tends

not to work Depression doesn’t make you drink BUT, drugs do make you feel good

(however, less and less over time)

Myths of Addiction Treatment

Myth of Self-Medication

Myth of Character Weakness Weakness or willpower have little to

do with becoming addicted Educated, strong people succumb to

the best drugs in the world

Myths of Addiction Treatment

Myth of Self-Medication

Myth of Character Weakness

Myth of Holding One’s Liquor The “Wooden Leg” Syndrome predicts

alcoholism, not immunity to alcoholism

Myths of Addiction Treatment

Myth of Self-Medication

Myth of Character Weakness

Myth of Holding One’s Liquor

Myth of Detoxification Getting sober is easy Staying that way is incredibly difficult Detoxification is preparatory step to

further treatment

Myths of Addiction Treatment Myth of Self-Medication Myth of Character Weakness Myth of Holding One’s Liquor Myth of Detoxification Myth of Brain Reversibility

Addiction produces permanent neurotransmitter and chemical changes

“Kindling” increase risk of permanent paranoia and hallucinations (from alcohol and stimulants)

Facts of Addiction Treatment

Addiction is a brain disease

Chronic, “cancerous” disorders require multiple strategies and multiple episodes of intervention

Treatment works in the long run

Treatment is cost-effective

Common Characteristics of Addict-Criminal Offenders

Unemployment

Criminal justice recidivism

Inability to cope with stress or anger

Highly influenced by social peer group

Inability to handle high-risk relapse situations

Common Characteristics…

Emotional and psychological immaturity

Difficulty relating to family

Inability to sustain long-term relationships

Educational and vocational deficits

Addiction is a Brain Disease

…with biological, sociological and

psychological components

Nature of Addiction

Loss of control

Harmful Consequences

Continued Use Despite Consequences

Three “C’s” of Addiction Control

Early social/recreational use Eventual loss of control Cognitive distortions (“denial”)

Compulsion Drug-Seeking activities Continued use despite adverse consequences

Chronicity Natural history is of multiple relapses preceding

stable recovery Relapse after years of sobriety is possible

Compliance & Chronicity

Chronic Illness

MedicationCompliance

Relapse within 1 yr.

Diabetes <60% 30-50%

Hypertension <40% 50-70%

Asthma <40% 50-70%

Addiction 30-50%

McLellan AT, Lewis DC, O’Brien CP, Kleber HD; Drug Dependence, A Chronic Medical Illness, JAMA, Oct 4, 2000

AbstinenceAbstinence

Strictly speaking, abstinence is developed, not recovered

It is an abnormal condition, signifying an internal defect (disease)

Addicts want to be “normal,” that is, using drugs in control

Self-ControlSelf-Control

Addicts seek control, not abstinence

Self-ControlSelf-Control

Addicts seek control, not abstinence

If I can have just one,

then I will be normal, just

like my friends

If I can have just one,

then I will be normal, just

like my friends

What is recovered in Recovery ?What is recovered in Recovery ?

Abstinence

Range of Emotions

Intimacy

Addiction Risk Factors Genetics

Young Age of Onset

Childhood Trauma (violent, sexual)

Learning Disorders (ADD/ADHD)

Mental Illness Depression Bipolar Disorder Psychosis

Alcohol 101 Genetics = 60% of Risk

Males >> Females

Available Medications Antabuse (Disulfiram): Deterrence ReVia (Naltrexone): Relapse Prevention Vivitrol (Naltrexone): Relapse Prevention Campral (Acamprosate) Relapse Prevention

Effective Treatments 12-Step Cognitive-Behavioral Therapy Counseling

Alcohol: Rate of Metabolism = 1.0-1.5

standard drinks per hour Beer 12.0 oz. 5% ABV Wine 05.0 oz. 12.5% ABV Liquor 01.5 oz 40% ABV

2nd and 3rd DUI/DWI’s are more diagnostic than 1st

Intoxication increases risk of suicide and homicide

Alcohol: Cognitive Deficits Memory Disorders

Impaired Abstraction

Perseveration using failed problem-solving strategies

Loss of Impulse Control

“Alcoholic Dementia” is similar to Alzheimer’s, but shows some improvement with sobriety

Biological Lens

Genetic predisposition 60% of alcoholism variance is predicted by

genetics• Animal Breeding Studies• Family Tree Studies• Adoption and Twin Studies• High-Risk Inheritance Paradigms

Neurotransmitters shifts Dopamine & Reward Pathways

Genetic InheritanceGenetic Inheritance

Human Family Tree Studies Alcoholism runs in families

“Drunks beget drunkards” – Plutarch 60 A.D.

Males have higher rates of alcoholism than females

Females may have more depression

Males show more antisocial behaviors

Genetic InheritanceGenetic Inheritance

Twin Adoption Studies Alcoholic family twin raised by non-

alcoholic foster parents 4X increase in alcoholism for males 9X increase if father is antisocial

Non-alcoholic family twin raised by alcoholic foster parents

No increased risk

Cocaine 101

Freebase (crack) since 1985

No medications are effective

Psychosocial treatments, including Cognitive-Behavioral Therapy and Relapse Prevention are effective

Risk of permanent “kindling” of paranoia and hallucinations

Cocaine: Functional Imaging

Methamphetamine

Synthetic made from ephedrine

Long-Acting, up to 12+ hours

Paranoia, Auditory Hallucinations

“Burnt-Out Speed Freak” Persistent paranoia and hallucinations Anhedonic lack of pleasure

The Brain

Hijacking the Reward System

Food

Sex

Excitement

Comfort

Dopamine Spells REWARD

Brain Reward Pathways

Activation of Reward

Heroin 101 New production in South America

High purity/potency (smokeable)

Detoxification is of limited long-term efficacy

Most effective treatment for chronic users is Methadone Maintenance

Medications Methadone, LAAM Replacement Buprenorphine Replacement Naltrexone Opioid Blockade

Death Rates in Treated and Untreated Addicts

0

1

2

3

4

5

6

7

8

MMT VOL DC TX INVOL DC TX UNTREATED

OBSERVEDEXPECTED

% Annual Death Rates

Slide data courtesy of Frank Vocci, MD, NIDA – Reference: Grondblah, L. et al. Acta Pschiatr Scand, P. 223-227, 1990

Impact of MMT on IV Drug Use for 388 Male MMT Patients in 6 Programs

PE

RC

EN

T I

V U

SE

RS

0

100

LA

ST

AD

DIC

TIO

N P

ER

IOD

AD

MIS

SIO

N

100%

81.4%

Pre- | 1st Year | 2nd Year | 3rd Year | 4th

*

*

63.3%

41.7%

28.9%

Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

Crime among 491 patients before and during MMT at 6 programs

0

50

100

150

200

250

300

A B C D E F

Before TX

During TX

Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

Cri

me

Day

s P

er Y

ear

Relapse to IV drug use after MMT105 male patients who left treatment

28.9

45.5

57.6

72.2

82.1

0

20

40

60

80

100

IN 1 to 3 4 to 6 7 to 9 10 to 12

Pe

rce

nt

IV U

se

rs

Months Since Stopping Treatment

Opioid Agonist Treatment of Addiction - Payte - 1998

Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

Twelve-Step Groups

Myths Only AA can treat

alcoholics Only a recovering

individual can treat an addict 12-Step groups are intolerant of

prescription medication Groups are more effective than

individuals because of confrontation

Twelve-Step Groups Facts

Available 7days/week, 24 hrs/day Work well with professionals Primary treatment modality is

fellowship (identification) Safety and acceptance

predominate over confrontation Offer a safe environment to

develop intimacy

Therapeutic Communities Cost-effective, long-term care Effective in treating sociopathic,

anti-social personalities Often very confrontational and

dogmatic Risks of charismatic leadership &

program corruption

Public Health

Drug treatment is disease prevention

HIV Infection reduced 6-fold in injecting drug users

>90% injection drug users are infected with Hepatitis C virus

How Long Should Treatment Last ? Depends on patient problems/needs

Less than 90 days is of limited or no effectiveness for residential / outpatient setting

A minimum of 12 months is required for methadone maintenance

Longer treatment is often indicated

Coercion

Treatment does not need to be voluntary to be effective. Court-Ordered Probation Family Pressure Employer Sanctions Medical Consequences

“Costly” or “Cost-Effective” Expensive Incarceration: Treatment is less

expensive than not treating or incarceration (1 year of methadone maintenance = $3,900 vs. $25,900 for imprisonment)

1:7 Rule: Every $1 invested in treatment = up to $7 in reduced crime-related costs

Health Offset: Savings can be > 1:12 when health care costs are included

Reduced interpersonal conflicts

Improved workplace productivity

Fewer drug-related accidents

Treatment Effectiveness Drug dependent people who participate

in drug treatment Decrease drug use Decrease criminal activity Increase employment Improve their social and intrapersonal functioning Improve their physical health

Drug use and criminal activity decrease for virtually all who enter treatment, with increasingly better results the longer they stay in treatment.

Medical Detoxification

Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.

High post-detoxification relapse rates Not a cure ! A preparatory intervention for further

care

MedicationsMedications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

Alcohol: Naltrexone, Disulfiram, Acamprosate, Odansetron

Opiates: Naltrexone, Methadone, Buprenorphine

Nicotine: Nicotine replacement (gum, patches, spray), bupropion

Stimulants: [None to date]

Discussion

End