Statistics

1

A New Paradigm for Recovery University of
Florida Scott Teitelbaum, M.D. FASAM, FAAP, Vice
Chairman Chief of Addiction Medicine
2
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 ones 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.

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Addiction is a Developmental Disease

1.8
TOBACCO
THC
1.6
ALCOHOL
1.4
1.2
1.0
in each age to develop first-time dependence
0.8
0.6
0.4
0.2
0.0
70
75
5
10
15
20
25
30
35
40
45
50
55
60
65
Age
Age at tobacco, at alcohol and at cannabis
dependence, as per DSM IV
National Epidemiologic Survey on Alcohol and
Related Conditions, 2003
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Gateway Drug
5
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

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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

8
Access predicting introduction to use

• As to obtaining prescription opiates, gt50 of
  12th graders were given the drugs or bought them
  from a friend or relative
• Despite age groups internet facility, number
  purchasing opioids on internet was negligible

9
Inherent trust of prescribed drugs

• Less harmful because medically administered
• Dosage regulated by medical profession and
  governmental oversight
• Purity of substance and quality control

10
Might Not Meet Todays FDA Standards
11

• 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

12
National Institute on Alcohol Abuse and Alcoholism

• 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

13
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.

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Designer DrugsWhats New Ongoing
G
Speed
E
Ecstasy

BZP
Special K
Crystal
Pot
DMT
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Its All About Sensation
Serotonin rush

• Smell sensation is intensified by the high,
  resulting in a pleasurable effect from the fumes
• Vicks inhalants, cough drops, surgical masks with
  med rub

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Neurotoxicity of Drugs
substantia nigra
locus ceruleus
Whats happening at the cellular level?
17
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

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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
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Marijuana Perceived Risk vs. Use
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Adolescents with AUD still appeared to have
reduced neuropsychological functioning after 3
weeks of abstinence
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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- 20s. Substance use can impair
  healthy brain development
• Emotional coping skills often delayed as a result
  of substance use

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ADDICTION IS A DISEASE OF THE BRAIN Like other
diseases, it affects tissue function
Decreased Heart Metabolism in Heart Disease
Patient
Healthy Heart
Sources From the laboratories of Drs. N. Volkow
and H. Schelbert
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Hypofrontality in Cocaine Dependent Patients
Reduced Metabolic activity at baseline in cocaine
dependent subjects
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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 Drugs
Amygdalanot lit up
Amygdalaactivated
Front of Brain
Back of Brain
Nature Video
Cocaine Video
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The Adolescent Brain is Still Developing
Amygdalo-cortical Sprouting Continues Into Early
Adulthood
Childhood
Adolescence
Adult
During Adolescence the COGNITION-EMOTION
Connection is Still Forming
Brain areas where volumes are smaller in
adolescents than young adults
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.
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Brain Mapping
Talking
Female
Nagging Area
Wine Drinking
Shopping
More Shopping
Feelings Central
Affinity for Shiny Objects
Sex Particle
Grudge Holding and Recounting Center
Courtesy of Paul Earley / TRC
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Brain Mapping
Male
Blank Stare
Beer Drinking
Belching and Gas Expulsion
Sex
More Sex
Video Games
Crotch Scratch
Commitment Particle
TV Remote Control Coordination Center
Courtesy of Paul Earley / TRC
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Adolescent Brain

• These brain changes are relevant to adolescent
  behavior
• Prefrontal cortex (PFC) is pruned and not fully
  developed until mid-20s
• Amygdala (and n.a.) show less pruning and tend to
  dominate the PFC

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Adolescent Brain Changes
prefrontal cortex

• These brain changes are relevant to adolescent
  behavior
• Prefrontal cortex (PFC) is pruned not fully
  developed until mid-20s
• Amygdala (and n.a.) show less pruning and tend to
  dominate the PFC

amygdala
nucleus accumbens
judgment
reward system
Ken Winters, Ph.D.
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Judgment vs. Reward
Prefrontal Cortex Judgment
Amygdala Reward System
Nucleus Accumbens
Ken Winters, Ph.D.
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Adolescent Brain

• This imbalance leads to... ? planned thinking
  ? impulsiveness ? self-control ? risk-taking

Drugs are bad!
I like to use drugs!
PFC
amygdala
Ken Winters, Ph.D.
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• From Oops to Dependence

Ken Winters, Ph.D.
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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.
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Reward System

• The reward system is responsible for seeking
  natural rewards that have survival value
• seeking food, water, sex, and nurturing
• Dopamine is this systems primary neurotransmitter

Ken Winters, Ph.D.
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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

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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
40
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
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Socio-cultural
Biological
The processes that initiate and maintain
alcoholism are regulated by interactions among
nerve cells in the brain.
Influences susceptibility to drug usage
Psychological
Environmental
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NIH/NIDA
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Cannabis Abuse and the Adolescent Brain
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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-20s, a subset maintain daily, long-term use

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Marijuana- Potency D.E.A. Seizure Data
46
Marijuana- Withdrawal

• Proposed Syndrome for DSM-V
• Common Sx
• Anger or aggression
• Decreased appetite or weight loss
• Irritability
• Nervousness/anxiety
• Restlessness
• Sleep difficulties, including strange dreams
• Equivocal Sx
• Chills
• Depressed Mood
• Stomach Pain
• Shakiness
• Sweating

• Relatively mild not recognized in DSM-IV
• Precipitated by cannabanoid antagonist
• Duration 1-30 days

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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

48
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

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CANNABIS AND THE BRAIN

• Increased risk of schizophrenia
• Reduced Thalamus size
• Decreased IQ
• Decreased efficiency of executive function
• Hyperactive reward centers

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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

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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.
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Marijuana Use Linked with Increased Risk of Motor
Vehicle Crashes

• Greater the amount of marijuana in a persons
  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.
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USER PROFILE

• Users typically start in late teens
• Use peaks in 20s
• Use dramatically declines with association of
  starting families and careers
• 10 will become daily users
• 20-30 will become weekly users

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Treatment of Young Adults

• 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

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Approaches to Treatment of the Young Adult

• 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

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Relapse Rates Are Similar for Drug Dependence And
Other Chronic Illnesses
Addiction Treatment Does Work
100
90
80
70
60
Percent of Patients Who Relapse
50
40
30
20
10
0
Drug Dependence
Type I Diabetes
Hypertension
Asthma
Source McLellan, A.T. et al., JAMA, Vol 284(13),
October 4, 2000.
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Treatment Today

• Only 1 in 10 Americans who need treatment receive
  it
• Of those that need it, approximately 95 dont
  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

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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).

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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).

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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.

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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).

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Treatment Works, BUT

• LOW ATTRACTION
• Only 10 of those needing treatment received it
  in 2002 (SAMHSA, 2003) access compromised by
  waiting lists (Donovan, et al, 2001).
• HIGH ATTRITION
• More than half of clients admitted to addiction
  treatment do not successfully complete treatment

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Treatment Works, BUT

• LOW SERVICE DOSE
• Inadequate 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)

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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.

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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

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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

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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

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Lessons from the PHPS

1. Zero tolerance for any use of alcohol and other
   drugs
2. Thorough evaluation and patient-focused (rather
   than program-focused) care
3. Prolonged, frequent random testing for both
   alcohol and other drugs
4. Effective use of leverage
5. 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

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The New HIGHER Standard

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

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New Paradigm in the CJS

• Hawaiis Opportunity Probation with Enforcement
  (HOPE) and South Dakotas 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

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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)
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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

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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
  unseen
• HOPE and 24/7 Sobriety programs produced lower
  rates of new crimes and lower rates of
  incarceration
• Use 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

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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

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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!

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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

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What is recovery? A working definition from the
Betty Ford Institute

• The Betty Ford Institute Consensus Panel
• Journal of Substance Abuse Treatment 2007 33
  221-228.

• There 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.

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The Betty Ford Institute Consensus Pane (Dr
Gold was a member of this panel )Journal of
Substance Abuse Treatment , 2007 33221-228.

• Recovery a voluntarily maintained lifestyle
  characterized by
• Sobriety
• Early (1-11 months)
• Sustained (1-5 years)
• Stable (gt 5 years)
• Personal health
• Physical
• Mental
• Social
• Spiritual
• Citizenship
• Giving-back
• Quality of life

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

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Recovery
Drug Use
Addiction
Treatment
Normal
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The Great ChallengeFor Addiction Treatment in
21st Century

• To Integrate
• Addiction Medicine, Psychiatry and Spirituality
  in the Treatment of Substance Use Disorders.

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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