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S. Alex Stalcup, M.D.

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Title: S. Alex Stalcup, M.D.


1
S. Alex Stalcup, M.D.
  • New Leaf Treatment Center
  • 251 Lafayette Circle, Suite 150
  • Lafayette, CA 94549
  • Tel 925-284-5200
  • Fax 925-284-5204
  • alex_at_nltc.com www.nltc.com

2
Definition of Addiction
  • Compulsion loss of control
  • The user cant not do it s/he is compelled to
    use.
  • Compulsion is not rational and is not planned.
  • Continued use despite adverse consequences
  • An addict is a person who uses even though s/he
    knows it is causing problems.
  • Addiction is staged based on adverse
    consequences.
  • Craving daily symptom of the disease
  • The user experiences intense psychological
    preoccupation with getting and using the drug.
  • Craving is dysphoric, agitating and it feels
    very bad.
  • Denial/hypofrontality distortion of cognition
    caused by craving
  • Under the pressure of intense craving, the user
    is temporarily blinded to the risks and
    consequences of using.

3
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4
2000 Smoking Prevalence
  • 70 of all cigarettes smoked in the United States
    are consumed by people with psychiatric and/or
    substance abuse disorders.
  • Smoking rates in schizophrenic individuals exceed
    80.
  • Smoking rate in individuals with major depression
    and other mood and anxiety disorders is 41
  • Smoking rate in individuals with alcoholism,
    heroin dependence or other illicit drug use is
    67.9
  • Smoking prevalence in the US in 2000 was 23.3

5
Dual Diagnosis
  • Mental Illness symptoms interact with drug
    effects.
  • Intoxication relieves symptoms of mental illness
  • Tolerance exacerbates symptoms of mental illness
  • Withdrawal exacerbates symptoms of mental illness

6
Prevalence of smoking in individuals with PD and
SUD
7
Nicotine and Alcohol
  • Animal studies show that nicotine increases
    voluntary alcohol intake.
  • 50 to 90 of alcohol-dependent individuals smoke
    regularly.
  • Regular smokers consume more alcohol than
    nonsmoking alcoholic individuals.
  • Alcoholic individuals who smoke continue to
    demonstrate a high level of nicotine dependence
    during abstinence from alcohol.
  • Chronic cigarette smoking in alcoholic
    individuals is associated with significantly
    higher quantity and frequency of alcohol
    consumption compared with nonsmoking or
    former-smoking alcohol-dependent individuals.
  • Alcoholic smokers have more severe nicotine
    dependence and greater difficulties quitting than
    nonalcoholic smokers.
  • In a US cohort treated for alcoholism, mortality
    associated with cigarette smoking was 51,
    whereas mortality related to alcohol-induced
    diseases alone was about 34.
  • More than 4 times as many Americans die from
    smoking-related than from alcohol-related causes.

8
Smoking Prevalence
  • 75.5 ever smoked
  • 63.3 smoked whole cigarette
  • 42.8 ever smoked daily
  • 21.7 ever nicotine dependent
  • 14.1 current nicotine dependence
  • 42.8 ever smoked daily
  • ?
  • 53.1 ever nicotine dependent
  • ?
  • 66.2 current dependence

9
Tobacco Dependence is a Pediatric Disease
  • 80 of smokers have risk factors known in
    childhood
  • Family history of addiction
  • ADHD (attention deficit hyperactivity disorder)
  • Mood disorder (depression, anxiety, trauma)
  • School failure
  • 89 of adult smokers try cigarettes before age 18
  • 71 of adult smokers are regular smokers at age 18

10
Prenatal Nicotine Exposure in Rat Pups
  • Fig. 1 ADHD
  • Increased locomotion
  • Fig. 2 ADDICTION
  • Increased preference for cocaine
  • Fig. 3 DEPRESSION
  • Increased learned helplessness

11
Adjusted Odds Ratio for ADHD among US Children by
Prenatal Tobacco Exposure and Sex
12
What is a Drug?
  • A drug is a pleasure producing chemical. Drugs
    activate or imitate chemical pathways in the
    brain associated with feelings of well-being,
    pleasure and euphoria.

13
Neuroadaptation
  • In direct response to overstimulation, brain
    regions decrease in sensitivity and
    responsiveness. Brain regions become
    unresponsive (deaf) to usual levels of
    stimulation, a process by which the reward and
    pleasure centers of the brain adapt to high
    concentrations of pleasure neurotransmitters
    (tolerance).
  • Under unstimulated conditions (without drugs)
    there is profound interference with the ability
    to experience normal pleasure. When sober, the
    user feels anhedonia, anxiety, anger, frustration
    and craving.
  • In addition to pleasure neuroadaptation, other
    brain pathways stimulated by drugs also become
    under active, directly leading to anxiety,
    depression, and loss of energy.
  • Once neuroadapted, the pleasure system remains
    impaired for months to years, interfering with
    sobriety, learning, and impulse inhibition.

14
Principles of Addiction Biology
  • Drugs and alcohol activate the pleasure-producing
    chemistry of the brain and the brain circuits
    that govern calm and alertness.
  • Over-stimulation of brain circuits causes them to
    neuroadapt which interferes with the normal
    experiences of pleasure, calmness and alertness.
  • Addiction is a disease of the pleasure-producing
    chemistry of the brain and related brain
    circuits Overstimulation causing neuroadaptation
    is the mechanism of the disease.
  • Transition to addiction from substance abuse
    arises from the development of tolerance and
    withdrawal.
  • With neuroadaptation, cessation of drug use leads
    to inversion of the high sobriety becomes
    pleasureless, anxious, sleepless and without
    energy.

15
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16
Environmental Cueing Conditioned Craving
  • Drug pleasure becomes associated with specific
    people, places, and things to encounter any of
    those things in the environment is to trigger
    craving for the drug. Such triggers persist for
    decades after use.

17
Behavior Control The Balance Concept
Forebrain
Decision Making
Logic
Drug Craving
Judgment
Cueing
Ethics
Hunger
Salience (weighing value)
Greed
Lust
Weighing consequences
Fear
Rage
Jealousy
Midbrain
18
?D2 Hypofrontality
  • Baseline metabolism falls in the prefrontal
    cortex secondary to decreased excitatory dopamine
    input.
  • Impaired decision making results from direct
    interference with reasoning, logic, and the
    ability to weigh consequences.
  • Drives, impulses, and craving are not inhibited
    because of direct compromise of brain reasoning
    ability.
  • The mind overvalues reward, fails to appreciate
    risk, and fails to activate systems that warn of
    impending danger.
  • The mind misjudges using as worth it by being
    unable to appreciate adverse consequences.

19
Addiction Pathophysiology
  • Hedonic Dysregulation
  • Dysphoria
  • Persistent boredom
  • Drug hunger
  • ?D2 Hypofrontality
  • Decreased recall of adverse consequences
  • Over value reward -- Under value risk
  • Impaired impulse control
  • Conditioned Craving
  • Drug-Specific Neural Dysregulation
  • Alcohol / benzodiazepines
  • anxiety, insomnia, hypertension
  • Opiates pain, anxiety, insomnia

20
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21
Nicotine EffectsReceptor Activation
  • Increase arousal
  • Heighten attention
  • Influence stages of sleep
  • Produce states of pleasure
  • Decrease fatigue
  • Decrease anxiety
  • Reduce pain
  • Improve cognitive function

22
Nicotine Receptor Activation
23
Brain Circuit Neuroadaptation
  • Over-stimulation causing neuroadaptation affects
    all brain circuits.
  • Each drug type affects specific circuits, in
    addition to pleasure circuits.
  • Drug-specific circuits cause a mixture of
    sedation and stimulation (intoxication).
  • Once neuroadaptation develops (tolerance), there
    will always be withdrawal symptoms that are the
    mirror image of the drug effects.
  • With neuroadaptation, cessation of drug use
    leads to inversion of the high sobriety
    becomes pleasureless, anxious, sleepless, and
    lacking energy

24
Nicotine EffectsWithdrawal Symptoms
  • Mentally sluggish
  • Inattentive
  • Insomnia
  • Boredom and dysphoria
  • Fatigue
  • Anxiety
  • Increase pain sensitivity
  • Worsen cognitive function

25
Differences in Neuroadaptation between Nicotine
and other Addicting Drugs
  • Tolerance to most drugs develops over weeks to
    months and resolves in months to years.
  • Tolerance to nicotine develops over a single day
    and resolves over night.

26
Model for nicotine addiction cycle during daily
cigarette smoking.
27
RISK OF ADDICTION
  • Positive and Negative Reinforcement
  • If, in addition to producing pleasure (positive
    reinforcement), a drug is more addicting if it
    relieves negative states boredom, anxiety,
    depression or stress (negative reinforcement).

28
Bio-Psycho-Social Model
  • Predisposition
  • Genetics
  • Childhood Sexual Abuse
  • Mental Illness
  • Acquired Hypofrontality
  • in utero alcohol/drug exposure low birth
    weight
  • perinatal asphyxia head injury
  • The Drug / Circumstances of First Use
  • Enabling System

29
Addiction Risk Resilience
  • Inherited predisposition (genetics)
  • Childhood trauma or abuse
  • Unwanted sexual involvement before age 13
  • Mental Illness depression, anxiety, personality
    disorder
  • Attention Deficit Disorder (ADD)
  • Learning disabilities/school failure
  • Subjected to teasing, bullying
  • Acne and/or obesity
  • Other than heterosexual orientation
  • Social rejection
  • Early sexual involvement
  • Onset of drug use before age 16
  • Enabling environment
  • Ignorance
  • No family history of addiction
  • Good mental health
  • Academic competence
  • Positive relationship with an adult
  • Family eats dinner together 5 days/wk
  • Peer group participation (clubs)
  • Participation in sports
  • Participation in music, drama or dance
  • Involvement in faith-based activities
  • Taking care of pets
  • Volunteer activities
  • Social acceptance
  • Environment disapproves of drug use
  • Immediate, appropriate scaled consequences for
    alcohol/drug use.
  • Early intervention for alcohol/drug use

30
Smoking Trajectories of Adolescent Novice Smokers
  • 72.4
  • Did not progress to addiction
  • School has clear rules on smoking
  • 27.6 Did progress to addiction
  • Development of nicotine dependence
  • Poor academic performance
  • More than half of friends smoke
  • Students smoke despite school rules
  • Parents smoke nicotine
  • Teachers/staff smoke near school
  • Co-morbidity highly prevalent
  • 11.1
  • Slow Use Escalation
  • Female gender
  • 10.8
  • Moderate Use Escalation
  • Female gender
  • 5.7
  • Rapid Use Escalation
  • Male gender
  • High co-morbidity
  • Strong family history for addiction

31
Goals of Assessment
Generation of a Treatment Plan
  • Is the client an addict?
  • Evidence of out of control use, in the face of
    adverse consequences, driven by craving and
    facilitated by denial.
  • What combination of factors in the
    Bio-psycho-social model led to addiction?
    Genetics, mental illness, sexual trauma,
    hypofrontality, enabling system.
  • What four causes of craving perpetuate the
    addiction? Environment, withdrawal, mental
    illness, stress
  • What are the barriers to sobriety?

32
Are you at Risk?
  • Apply the bio-psycho-social model to yourself
  • Do you have a family history of addiction?
  • Do you have a tendency to boredom or ADHD?
  • Are you anxious or depressed?
  • Have you suffered sexual trauma?
  • Do you have an effective way to manage stress?

33
Are you in trouble?
  • How can you tell if you are getting into trouble?
  • Are you compulsive?
  • Is use causing adverse consequences?
  • Do you crave the drug?
  • If so, when you crave the drug, can you talk
    yourself into using it, even when you had
    resolved to not use?
  • When you have resolved not to use, do you find
    yourself using under known craving conditions
    environment, withdrawal (bored, irritable, sleep
    disordered), anxiety or blue, or when you are
    stressed?

34
Are You an Addict?
  • TRY THE EXPERIMENT
  • Resolve not to use for 5 weeks.
  • Go about your usual daily activities.
  • Put yourself around the drug and people using it.

35
Are You an Addict?
  • AFTER 5 WEEKS
  • Were you able to not use?
  • Did you find your mind talking you into using?
    Did you struggle not to use?
  • Were you able to have pleasure without using?
  • Did you have problems with boredom, depression or
    anxiety?

36
What to do
  • Get out of the using environment.
  • Find alternative sources of pleasure.
  • Work on balancing stress.
  • Seek help for mental health issues and other
    personal stresses.

37
Definition of Addiction
  • Compulsion loss of control
  • The user cant not do it s/he is compelled to
    use.
  • Compulsion is not rational and is not planned.
  • Continued use despite adverse consequences
  • An addict is a person who uses even though s/he
    knows it is causing problems.
  • Addiction is staged based on adverse
    consequences.
  • Craving daily symptom of the disease
  • The user experiences intense psychological
    preoccupation with getting and using the drug.
  • Craving is dysphoric, agitating and it feels
    very bad.
  • Denial/hypofrontality distortion of cognition
    caused by craving
  • Under the pressure of intense craving, the user
    is temporarily blinded to the risks and
    consequences of using.

38
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39
C I M Model TreatmentCraving Identification
and Management
Stalcup SA, Christian D, Stalcup JA, Brown M,
Galloway GP. A treatment model for craving
identification and management. Journal of
Psychoactive Drugs. 38235-44, 2006
40
C I M Model Treatment Causes of Craving
  • Environmental cues (Triggers)
  • immediate, catastrophic, overwhelming craving
    stimulated by people, places, things associated
    with prior drug-use experiences
  • Drug withdrawal
  • inadequately treated or untreated
  • Mental illness symptoms
  • inadequately treated or untreated
  • Stress equals craving

41
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42
C I M Model TreatmentComponents of Treatment
  • Initiation of Abstinence Stopping Use
  • Drug Detoxification Use of medications to
    control withdrawal symptoms
  • Avoidance Strategies Measures to protect the
    client from environmental cues
  • Schedule Establishing times for arising,
    mealtimes, and going to bed
  • Mental Health Assessment and Treatment
  • Relapse Prevention
  • Drug Detoxification Continued use of medications
    to control withdrawal
  • Avoidance Strategies Controlled re-entry to
    cue-rich environments
  • Schedule Adherence to a regular daily lifestyle
  • HUNGRY Three regularly spaced meals each day
  • ANGRY Separate feelings of anger from losing
    control of behavior
  • LONELY One positive social contact per day
    minimum
  • TIRED Daily practice of sleep hygiene
  • Tools Behaviors that dissipate craving
  • Exercise Spiritual Practice Talk
    Peer Support Groups Counseling Having
    Fun
  • Mental Health Treatment

43
TOBACCO CESSATION Initiating Abstinence
  • Establish therapeutic alliance
  • Assess biopsychosocial model
  • Risk factors
  • Circumstances of initial use
  • Use History and prior quit attempts
  • Assess four causes of craving
  • Environment Other smokers in (home, work,
    school)
  • Paraphernalia in environment
  • Mental Health treatment plan
  • Withdrawal management plan
  • Stresses associated with smoking
  • 4. Set Quit Date

44
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45
TOBACCO CESSATION Relapse Prevention
  • Monitor use, craving scores, adherence to plan
  • Modify plan to address weaknesses
  • Continue modified plan, assess craving scores and
    craving causes
  • Monthly telephone follow up calls

46
C I M Model TreatmentDetoxification
  • Use of medications to treat
  • withdrawal symptoms.

47
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48
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49
Continuous abstinence with varenicline,
bupropion, placebo
50
C I M Model TreatmentAvoidance Strategies
  • Measures to Protect the Client From Exposure to
    Environmental Cues
  • Identification of environmental cues
  • Development of avoidance strategies-specific plan
    to avoid each cue
  • Rehearsal of avoidance strategies
  • Implementation of avoidance strategies
  • changing phone numbers
  • seeking safe housing
  • avoiding old using haunts
  • separating from old using partners/situations
  • plans for handling money
  • Enforced isolation-strict avoidance of
    conditioned cues and total isolation from the
    using environment during the first four to six
    weeks of recovery.

51
C I M Model TreatmentRecovery Tools
  • Behaviors that dissipate craving
  • Exercise Two 20 minute exercise periods daily
  • Spiritual practices Meditation Prayer
  • Talk Treatment groups Journal writing
  • Peer support groups Narcotics Anonymous
  • Individual counseling Alcoholics Anonymous
  • Counseling Cognitive Behavioral Therapy (CBT)
  • Motivational Enhancement Therapy (MET)
  • Contingency Contracting
  • Baths/Showers hot or cold
  • Orgasm safe sex/self sex
  • Relaxation exercises using audio tapes or
    learned behavioral techniques
  • Having Fun

52
C I M Model TreatmentRelapse Prevention
  • Questions about Craving
  • What is your craving score?
  • What is the cause of your craving?
  • Environmental cue
  • Stress
  • Drug withdrawal
  • Mental health problems
  • What will you do to take care of yourself?
  • Avoidance strategies
  • Stress Management
  • Tools
  • Program activities
  • Principles
  • Addicted persons relapse because of craving.
  • Craving has causes that can be predicted,
    recognized and analyzed.
  • Craving can be managed with the use of program
    activities.

53
RECOVERY COACHING
  • How is it going are you able to not smoke?
  • What are your craving scores, now and highest in
    the last day
  • What cause of craving is the worst? (people
    smoking around them, persistent withdrawal,
    depression/anxiety/dysphoria, stressed
  • What are you going to do to take care of
    yourself?
  • Exercise
  • Change medications
  • Use tools

54
Treatment works!
  • Tobacco dependence is a chronic condition
    requiring repeated intervention.
  • Every client who uses tobacco should be offered
    treatment.
  • Brief treatment for tobacco dependence is
    effective.
  • Strong dose-response relationship between
    intensity of counseling (minutes of contact) and
    effectiveness
  • Pharmacotherapy is effective.
  • All clients should be offered medications to help
    them quit smoking.
  • Identifying and treating co-morbid conditions
    improves outcomes (anxiety, depression, PTSD,
    ADHD,SUD).
  • Treatment for tobacco dependence is clinically
    effective and cost- effective.

55
Prevention
  • Reduce prenatal nicotine exposure
  • Reduce prenatal alcohol and drug exposure
  • Identify high risk groups for early intervention
  • family history of addiction
  • prenatal nicotine/alcohol/drug exposure
  • perinatal asphyxia, poor cognitive development
  • Identify and treat ADHD
  • Identify and treat co-morbid mental health
    disorders, e.g., depression, anxiety, PTSD,
    thought disorders

56
REFERENCES
  • Benowitz N. Neurobiology of nicotine addiction
    implications for smoking cessation treatment.
    American Journal of Medicine. 121(4A) S3-S10
    (2008).
  • Bechara A. Decision making, impulse control and
    loss of willpower to resit drugs a
    neurocognitive perspective. Nature Neuroscience.
    81458-63 (2005)
  • Dackis C, OBrien C. Neurobiology of addiction
    treatment and public policy ramifications. Nature
    Neuroscience. 8(11)1431-6 (2005).
  • Nestler EJ, Malenka RC. The addicted brain.
    Scientific American.com February 9, 2004.
  • Stalcup SA, Christian D, Stalcup JA, Brown M
    Galloway GP. A treatment model for craving
    identification and management. Journal of
    Psychoactive Drugs. 38235-44, 2006
  • Volkow ND, Fowler JS, Wang GJ. The addicted human
    brain insights from imaging studies. Journal of
    Clinical Investigation. 111(101444-51 (2003).
  • Weinberger DR, Elvevag B, Giedd JN. The
    adolescent brain a work in progress. National
    Campaign to Prevent Teen Pregnancy. June 2005.
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