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The Chronic Disease of Addiction Evidence and Lessons from Practice

Laura G. Kehoe, MD, MPH Medical Director, MGH Substance Use Disorders Unit Bridge

Clinic Massachusetts General Hospital

Assistant Professor of Medicine, Harvard Medical School

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Disclosures

I have the following relevant financial relationship with a commercial interest to

disclose

Guest lecture honoraria

Reckitt Benckiser

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Objectives

• Review of chronic, relapsing model of addiction

• Comparison with other chronic diseases

• Lessons from practice

• Lessons from patients

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“Addiction is Irrational”

• Primary, chronic brain disease characterized by compulsive drug seeking and use despite harmful consequences

• Involves cycles of relapse and remission

• 40-60% genetic

• Without treatment addiction is progressive and can result in

disability or premature death

American Society of Addiction Medicine. April 12, 2011. www.asam.org

NIDA. August, 2010. http://www.drugabuse.gov/publications/science-addiction

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Addiction is a Developmental Disease

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Childhood Dreams and Aspirations

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Acute Care Model As We Know It

relapse

detox

overdose relapse

detox

overdose

“Treatment”

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Can You Guess?

www.mghcme.org NIDA

Circuits Involved in Addiction

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Dopamine D2 Receptors are Lower in Addiction

Cocaine

Alcohol

Heroin

Meth

control addicted Volkow et al., Neuro Learn Mem 2002.

1.5

2

2.5

3

3.5

4

4.5

15 20 25 30 35 40 45 50

DA

D2

Rec

epto

rs

(Rat

io In

dex

)

20 25 30 35 40 45 50

1.6

1.8

2

2.2

2.4

2.6

2.8

3

3.2`

Bm

ax/K

d

Normal Controls Cocaine Abusers

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Wit

hd

raw

al

No

rmal

Eu

ph

ori

a

Chronic use Acute use

Tolerance & Physical

Dependence

Slide courtesy of Dan Alford, 2012

Natural History of Opioid Use Disorder

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Healthy Brain

Decreased Brain Metabolism in Addiction

Diseased Brain Diseased Heart

Decreased Heart Metabolism in Coronary Artery Disease

Healthy heart

High

Low

Addiction is Similar to Heart Disease

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Functional Recovery Takes Time

Normal 1 month post-detox

14 months

Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001

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NIDA. Principles of Drug Addiction Treatment. 2012. McLellan et al., JAMA, 284:1689-1695, 2000 .

Addiction is a Treatable Disorder

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Comparable Relapse Rates

Slide courtesy of NIDA, Drugs, Brain Behavior: the Science of Addiction

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Extended Abstinence is Predictive of Sustained Recovery

It takes a year

of abstinence

before less than

half relapse

Dennis et al, Eval Rev, 2007

After 5 years – if you are sober,

you probably will stay that way.

Slide courtesy of NIDA, Drugs, Brain Behavior: the Science of Addiction

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Treating a Biobehavioral Disorder Must Go Beyond Just

Fixing the Chemistry

Pharmacological

Treatments

(Medications)

We Need to Treat the

Whole Person!

In Social Context

Behavioral Therapies

Social Services Medical Services

Slide courtesy of NIDA, Drugs, Brain Behavior: the Science of Addiction

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Stacey

• Stacey is a 43 yof with severe OUD, remote cocaine use disorder, tobacco use disorder, COPD with recurrent pneumonia, marital discord, DCF involvement, trauma.

• Starts Suboxone with stabilization at 20 mg daily eventually • Engaged and in remission x 12 mo, reunited with children, working • Needs lung biopsy, makes it through with increase Suboxone and

support • Rx Tramadol from surgeon - relapse • Re-engages – stabilizes x 9 months • Cravings in setting of custody battle, Rx adjusted • Stabilizes with increased support, stress reduction, tx of her anxiety • After another year, has pelvic surgery, pain, increased anxiety –

increase Suboxone and supports did well • Note: regarding courts

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Stephen

• Stephen is a 40 yom with long hx IVDU heroin, trauma, short stint in the reserves, and now homelessness.

• My first pt on Suboxone.

• Immediate engagement, feels “normal,” gets back to classes, ongoing insomnia

• 12 step meetings

• Early refill request

• UTOX + cocaine, THC

• Missed appt due to class

• On nightly news holding up a CVS for OxyContin

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Stephen

• Returned to clinic on probation

• Resumed Rx with shorter visit intervals, support, shorter Rx supplies, engagement in counselling, contingency mgmt, GAD treatment

• Engagement with VA housing

• Stabilizes on higher dose Suboxone and increased support

• Periodic relapses, each shorter

• Now in remission 2+ years

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Relapse Requires Increased Support

• We label patients as “not ready” or “non compliant”

• We ask them to seek a higher level of care on their own, when most ill

• We refer them for “higher level of care” – yet many of those programs are not evidence based, and are essentially lower level of care

• What would we do if a cancer survivor had a lymphoma recurrence after years of remission?

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“People Don’t Fail Treatment.

Treatment Fails People” • Deconstruct the relapse with your patient

• Good people make bad decisions when SUD active • Change takes time, patience and trust • When diseases flare, we increase care or enlist the care of other

team members. This is no different • Trust is an important tool • Positive reinforcement (contingency management) • Competing priorities • Communicate with others • “No one size fits all” just like other diseases

– Diet controlled pre-diabetes, oral agents, insulin for DM – Diet, exercise, statin, beta-blocker, ASA, ACE inhibitors for heart

disease

Ed Salsitz, MD

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Lessons Learned

• Listen to your patients • It’s hard to have an addiction • Diversion happens • Most have used Suboxone in the past and can do

home inductions • Don’t get caught up in the dose- splitting hairs – • Don’t forget about “pseudo-addiction” • Take sleep disturbance seriously – advance

Suboxone • Take report of cravings extremely seriously – treat

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What Next?

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