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THE DISEASE OF
ADDICTION:
A Primer
The 10th Annual Kinship Conference for
Grandparents and Relatives
South Burlington, Vermont
9 September 2014
3 BASIC QUESTIONS
AT THE KITCHEN TABLE
1. Why don’t they just stop?
2. Does treatment really work?
3. How does treatment work?
1. WHY DON’T THEY JUST STOP?
• “Those people are weak-willed, lazy,
irresponsible and sociopathic.”
• “Those people are dependent, moral
degenerates, liars and floozies.”
• “Those people could stop if they put their mind
to it.”
• “Equal opportunity destroyer”: not
correlated with gender, education,
professional status, or sociopathy
• BIO-BEHAVIORAL change from
voluntary control to compulsive &
uncontrollable
THE FACTS
ADDICTION:
SIMPLY DEFINED
Continued use despite
consequences.
ADDICTION:
(MIS)UNDERSTOOD
• Fundamental brain changes associated with
assault of toxic substances: Neuro-circuitry,
neurotransmitters, anatomy
• Changes in brain function: Judgment, memory,
impulse control, will (“brain quadriplegia”)
• Data: fMRI, PET scans, animal studies
• Current diagnostic methods are primitive
• Range in loss of biobehavioral control
BRAIN MOLECULAR TARGETS OF
DRUGS AND ALCOHOL
??Inhalants
Serotonin receptors
Serotonin receptors
NMDA receptors
NMDA receptors
Hallucinogens
LSD
MDMA
PCP
Ketamine
Dopamine transporters
Dopamine/NE release
Stimulants
Cocaine
Amphetamines
Opioid receptorsOpioids
Cannabinoid receptorsMarijuana/THC
GABA receptors
GABA receptors
Depressants
Barbiturates
Benzodiazepines
Nicotinic Ach receptorNicotine
Adenosine ReceptorsCaffeine
Classes of Drugs Primary Target
NMDA receptors (blocked)
Kainate receptors (blocked)
GABA receptors (stimulated)
Glycine receptors (stimulated)
Nicotinic Ach receptors (stimulated)
Serotonin receptors (stimulated)
Calcium channels (blocked)
Potassium channels (blocked)
Protein Kinase C
Protein Kinase A
DARPP-32
Phosphatases
Neurosteriods
Alcohol Targets
SUBSTANCE USE DISORDER
Diagnosis associated with:
• Alcohol
• Cannabis
• Phencyclidine
• Other hallucinogens
• Inhalants
• Opioids
• Sedatives, hypnotics, or anxiolytics
• Stimulants
• Tobacco
• Other (or unknown)
DIAGNOSTIC CRITERIA
Problematic pattern of substance use leading to
clinically significant impairment or distress, as
manifested by at least two of the following,
occurring within a 12-month period:
IMPAIRED CONTROL (Criterion 1-4)
1. Substance is often taken in larger amounts or over a
longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to
cut down or control substance use.
3. A great deal of time is spent in activities necessary to
obtain substance, use substance, or recover from its
effects.
4. Craving, or a strong desire or urge to use substance.
SOCIAL IMPAIRMENT (Criterion 5-7)
5. Recurrent substance use resulting in a failure to
fulfill major role obligations at work, school
or home.
6. Continued substance use despite having persistent or
recurrent social or interpersonal problems caused
or exacerbated by the effects of the substance.
7. Important social, occupational, or recreational
activities are given up or reduced because of
substance use.
RISKY USE (Criterion 8-9)
8. Recurrent substance use in situations in
which it is physically hazardous.
9. Substance use is continued despite knowledge
of having a persistent or recurrent physical or
psychological problem that is likely to have
been caused or exacerbated by substance.
PHARMACOLOGICAL CRITERIA (Criterion 10-11)
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of substance
to achieve intoxication or desired effect.
b. A markedly diminished effect with continued use of
the same amount of substance.
11. Withdrawal, as manifested by either of the
following:
a. The characteristic withdrawal syndrome for substance
b. Substance is taken to relieve or avoid withdrawal
symptoms.
SUBSTANCE USE DISORDER
• 11 Criteria
• Severity level:
0-1 = No Diagnosis
2-3 = Mild (~ Abuse)
4-5 = Moderate (~ Dependence)
6+ = Severe (~ Addiction)
ADDICTION SYMPTOMS:
TRAJECTORIES OF ONSET
BY SUBSTANCE
2. DOES TREATMENT REALLY WORK?
• No, look at all the “failures” and recidivism.
• No, it’s a sham, they can stop on their own if they really want to.
• Maybe, but only if they really want to.
ADDICTION TREATMENT:
COMPARISON WITH OTHER
CHRONIC DISEASES
Disease Inherited Outcome Relapse
HBP .25 - .50 60% 50 - 70%
Diabetes .80 60% 30 - 50%
Asthma .36 - .70 40% 50 - 70%
Addiction .34 - .52 40 - 60% 30 – 50%
(McLellan et al, JAMA, 2000)
VARIABILITY IN TREATMENT
OUTCOMES:
CHRONIC DISEASES
• Stage of the disease: Early to Advanced
• Socioeconomic status (insurance benefits)
• Family and social supports
• Comorbid psychiatric conditions
• Motivational stage of patient
• Quality of treatment: Index episode and
over time---Chronic disease management
ADDICTION TREATMENT:
(MIS)UNDERSTOOD
• Most people will not achieve maximum treatment
benefits from a single treatment
• No single treatment type is adequate
• The most effective treatments combine evidence-
based approaches and are delivered over time
• What happens outside of treatment is more
important than what happens inside
• The process of treatment & recovery can progress
from “life saving” to “life changing”
THE ACUTE CARE MODEL
NTOMS Sample of
250 Programs
TREATMENT
PATIENT WITH SYMPTOMS
PATIENT WITHOUT SYMPTOMS
ACUTE CARE MODEL: ASSUMPTIONS
1) Some fixed amount or duration of treatment will resolve the problem:
Outcomes determined after discharge
2) Clinical efforts put toward matching treatment and getting patients to complete treatment:
Single shot approach
3) Evaluation of effectiveness following completion:
Poor outcome means ineffective treatment
CHRONIC DISEASE MANAGEMENT:
ASSUMPTIONS
1) There are agreed upon clinical targets:
Abstinence, less severe symptoms
2) Some combinations of treatments will achieve the clinical targets:
Not just one single fixed treatment approach
3) There will be no discharge – just reduced intensity of care over time:
Recovery check-ups and monitoring
If addiction is a chronic disease
then:
We are neither treating nor evaluating
the effectiveness of its
treatments correctly.
0
2
4
6
8
10
Pre During During During Post
OUTCOME STUDIES WITH
HYPERTENSION
0
2
4
6
8
10
Pre During During During Post
OUTCOME STUDIES WITH
ADDICTION
LESSONS FROM CHRONIC DISEASE
MANAGEMENT & EVALUATION
•Most patients do not respond to their first
treatment (or medication).
•Treatment trials and combinations are most
common and may maximize benefits.
•Ongoing monitoring is an accepted part of
routine health care.
•Research (and clinical) evaluations of continuing
care should occur during treatments, & over
time.
MECHANISMS OF DENIAL
1. Biological: Memory, judgment, insight
2. Psychological: fear
3. Interpersonal: shame/guilt
4. Contextual: motives to disclose
5. Informational: knowledge of connections between
use & consequences
3. HOW DOES TREATMENT WORK?
• It works because you make them
change or else!
• You read them the riot act and break
through the denial.
• They must go to detox then residential
then aftercare then AA.
THE FACTS
• Understanding how treatment works is the
most important area of current research.
• Several things have been established:
1) Assessment & Engagement Strategies
2) Problem - Service Matching
3) Duration of Treatment Matters
AMERICAN SOCIETY OF ADDICTION
MEDICINE PATIENT PLACEMENT
CRITERIA (The ASAM Criteria)
No one size fits all.
1. Acute intoxication, withdrawal potential
2. Biomedical factors
3. Emotional/behavioral/cognitive factors
4. Readiness to change/Treatment acceptance
5. Continued use and relapse potential
6. Recovery environment
VOLUNTARY VERSUS MANDATED
TREATMENT
• Equivalent outcomes: Sustained over time
• Variety of contexts: Impaired physicians, transportation industry employees, addicted pregnant women, professional athletes
• Combination is better than one or the other alone:
Treatment w/sanction >
Treatment alone > Sanction alone
CORRELATES OF
LONG TERM RECOVERY (n = 660) Vaillant (1995)
• Duration of abstinence:
5+ years ~ remission
• Alternative positive activities
• Peer support group involvement
• New primary (romantic) relationship
• Spiritual connection
33
4.5%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
13%
14%
15%
Household
(OR=1.00)
Less than 1
(OR=2.87)
1-3 Years
(OR=1.61)
4-8 Years
(OR=0.84)
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
13%
14%
15%
Household
(OR=1.00)
Less than 1
(OR=2.87)
1-3 Years
(OR=1.61)
4-8 Years
(OR=0.84)
4.5%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
13%
14%
15%
Household
(OR=1.00)
Less than 1
(OR=2.87)
1-3 Years
(OR=1.61)
4-8 Years
(OR=0.84)
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
11%
12%
13%
14%
15%
Household
(OR=1.00)
Less than 1
(OR=2.87)
1-3 Years
(OR=1.61)
4-8 Years
(OR=0.84)
Source: Scott, Dennis, Simeone & Funk (2011)
Users/ Early Abstainers 2.87
times more likely to die in the next
year
The Risk of Death goes down with
years of sustained abstinence
It takes 4 or more years of abstinence for
risk to get down to
community levels
11.9%
7.1%
3.8%
RECOVERY: A DEFINITION
Betty Ford Institute Consensus Panel (2007)
Recovery from substance dependence is a voluntarily maintained lifestyle characterized
by sobriety*, personal health and citizenship**.
*Sobriety: Early: < 1yr; Sustained: 1-5 yrs; Stable: 5+ yrs
**Citizenship (Wikipedia): “…implies working towards the betterment of one’s community through participation, volunteer work, and efforts to improve life for all citizens.”
3 BASIC QUESTIONS
AT THE KITCHEN TABLE
1. WHY DON’T THEY JUST STOP?
2. DOES TREATMENT REALLY WORK?
3. HOW DOES TREATMENT WORK?
Mark McGovern
Professor
Department of Psychiatry &
Department of Community and Family Medicine
Geisel School of Medicine at Dartmouth
85 Mechanic Street, Suite B4-1
Lebanon, NH 03766
mark.p.mcgovern@dartmouth.edu
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