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Agenda

I. Introduction & Overview

II. The Disease of Addiction

III. Population and Risk Factors

IV. Treatment

V. Center for Addiction Medicine Initiatives

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Substance Misuse: The Nation‟s Number One Public Health Problem

There are more deaths, illnesses, and disabilities from substance use than from any other preventable health condition Of the more than 2 million deaths each year in the US, 1 in 4 is

attributable to alcohol, tobacco, and illicit drug use

Alcohol alone causes about 20–30% of esophageal cancer, liver cancer, cirrhosis of the liver, homicide, epileptic seizures, and motor vehicle accidents worldwide (WHO, 2002).

Over 22.6 million Americans have problem with alcohol or other drugs More than half of all families in the US has or has had a family member

suffering from alcohol dependence (NIAAA, 2005)

Alcohol use is involved in 25-50% of suicides

37% of those with alcohol dependence and 53% of those with dependence on an illicit drug have another psychiatric illness

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Economic Burden

The economic burden associated with alcohol misuse alone is approaching $200 billion annually, far exceeding the cost associated with other medical conditions such as cancer ($107 billion) and heart disease ($96 billion).

When combined with other drugs the economic burden is close to $400 billion annually.

Gruel and Rehm. 2003

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MGH Facts/Figures

At MGH Outpatient Addiction Services, approximately 2

out of 3 patients have co-occurring mental health and

substance use disorder diagnoses

Inpatients with an SUD primary or secondary diagnoses

had a LOS of 2.5 days longer than those without

Patients with alcohol use issues comprise 5% of all ED

visits, but 7.2% of ED bed hours, or 3 beds in any 24

hour period

32% admitted, compared to 26% of other patients

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Starkly Reduced Dopamine Receptor Expression Observed in Brain Reward Centers in the Striatum

6Morgan, et al., 2002, Nat Neurosci

Reduced D2 Receptor Expression Experimentally Induced by Social Stress and Correlation with Cocaine Self Administration

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3-D Iso-surface Representation of Amygdala in Cocaine Addiction Showing 23% Volume Reduction

Patients

Normal Controls

AnteriorPosterio

r

Superior

Right Lateral Ventricle = red

Left Lateral Ventricle = green

Common

Right Amygdala

Makris et al., 2004 Neuron

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Drug Administration/Drug-Seeking BehaviorFailed impulse suppression

Euphoria/Positive Reinforcementactivated reward pathways

NeuroadaptationsWithdrawal and ToleranceProtracted hedonic dysregulation

Drug Craving/Negative ReinforcementDysregulated reward pathways

Addictive agent

Drug-related cuesLimbic activation

Stress

Model of addiction

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Addiction

Addiction is a disorder of brain reward centers that normally insure the survival of organisms and the species

Drugs activate and dysregulate endogenous reward systems such that attention, motivation, behavior are directed away from

survival goals and toward drug-related cues

Dackis and O‟Brien, 2001

Defined by loss of control over intense urges to take the drug despite adverse consequences

Volkow and Fowler, Cereb Cortex 2000

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Onset

Substance use disorders typically have onset during adolescence and young adulthood and tend to have a chronic course without intervention - 90% of all adults with alcohol/drug dependence started using under the age of 18, half under the age of 15 (NSDUH, 2006) 75% of High School students have tried alcohol

Nearly 50% of seniors drink at least once a week

1 out of 4 seniors uses illicit drugs

1 out of 3 teens, age 14-17, have used an illegal drug more than once

Brain development continues well into mid-20‟s Sustained binge drinking may affect this process, may result in damage

to frontal-cortical regions

Early intervention and recovery management offers hope for shortening the intensity and course of the illness

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Age at Onset of DSM-IV Drug Abuse and Dependence

Compton et al. Arch Gen Psychiatry/ Vol 64, May 2007; 45(11): 1294 - 1303

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Who is Vulnerable?

Adolescents

40-60% of vulnerability for addiction genetically influenced

Addiction is more prevalent in people who have the following

childhood psychiatric disorders:

Depression and Bipolar Disorder*

Anxiety

Schizophrenia

Post-Traumatic Stress Disorder

Attention Deficit Hyperactivity Disorder

Conduct Disorder*

* Denotes largest risk factor: Over half develop substance abuse

N. Volkow, 2007, Director National Institutes on Drug AbuseGoldman, et al; ‘05 Nature Rev. Gen.; Hiroi, et al; ‘05 Mol Psychiatry

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Striatum & Hippocampus

Medial Wall

Prefrontal structures

Substances of Abuse are Deleterious in Adolescent Brain Development

Negative CNS effects of chronic alcohol use in teens:- Learning- Information recall, memory (verbal, nonverbal)- Vocabulary- Sleep (mood,

attention)

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Relationship between Mental Health and Substance Use Disorders

Complex, multifaceted

Genetics/ neurobiological

Affected by multiple systems of adolescent/young adult life Family, Community/ School, Peers, Media

Life stresses, academic and social issues

Dynamics-self medication

Changes with maturation, normal development

Substance use can worsen the severity of pre-existing mental health conditions; untreated mental health issues exacerbate substance use

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Clinical Imperative

Substance Use Disorders are Highly Prevalent,Under-recognized and Under-treated

Screening is fast and effective

Even brief intervention can effect salutary change

Early Intervention is optimal

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What Can Be Done?

Treatment works; extensive models are best suited to the nature of addiction

Effective treatments exist:

Pharmacotherapy

Rarely Prescribed

Cognitive-behavioral therapy

Motivational Interventions

Community Reinforcement Model

12-step facilitation

Family therapy

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Innovative Models of Care

Extensive models are best suited to the nature of addiction

“Aftercare” – Continuing Care – Treatment

Case monitoring

Recovery management

Assertive Continuing Care

Mutual Help Groups/Peer Support

Program Evaluation

Science-based practice

Practice-based science

Intermediate Outcomes/Theory

Provides for systematic evaluation; identification of patient subgroups/non-responders

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Treatment Challenges - Stigma

Conceptualized as a disorder of „Free Will‟

“substance abuser”

Perhaps even more than other mental illness, patients with substance use disorders feel strong sense of shame/embarrassment, and self-loathing

Shame associated with substance use creates a barrier to accessing treatment and disclosure/open communication

Substance use disorder is a chronic health condition similar to hypertension, diabetes and yet is not treated as such

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Is Substance-Related Treatment Worth Its Cost? Addiction treatment is highly cost-effective

Every $1 invested in addiction treatment programs yields a $4-7 saving in reduced drug-related crime, criminal justice costs, and theft alone.

When health care savings are included, total exceeds costs by ratio of 12 to 1

Major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents.

Measuring and Improving Cost, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs, U.S.

DEPARTMENT OF HEALTH AND HUMAN SERVICES, NIH, NIDA 1999.