Definingandtreatingaddiction

GTreismanMDPhD

LearningGoals

• Definecharacteristicsofaddiction• Discussdiseaseandbehavioralmodelsofaddiction

• Describeaframeworkforaddictiontreatment

Therapeuticvs Symptomatic(Inpsychiatryweneedtobewarecosmeticpsychopharmacology)

Therapeutic• Drugeffectstrytocounter

orcorrectpathology

• Goalistoimprovefunction

• Antidepressants• Neuromodulators

Symptomatic• Drugsblockoractivate

pathwaysthatproducesymptoms

• Goalistomakepeoplefeelbetter

• Anxiolytics• Opiates

Whatmakesadrug“addictive?

• 30,000,000knownchemicalsubstances,lessthan100areaddictive

• Addictivedrugsincludepsychostimulants,nicotine,opiates,cannabinoids,andethanolandrelatedGABAdrugssuchasbarbituratesandbenzodiazepines

• Allthedrugsare“rewarding”andanimals(includingpeople)willworktogetaccess

Addictions

DepressionDemoralizationChronicpainPhysicalInjury

Cognitiveimpairment

MedicalandPsychiatricmorbidity

ImpulsivityHighrisksexualbehavior

HomelessnessProximitytohighprevalence

DepressionDemoralization

Cognitiveimpairment

Coreconceptsofaddiction

• Tolerance– Increasingdose

• Dependence– Physicalwithdrawal

• Reinforcement– Providesbehavioralreinforcement

SubstanceAbuseDisorders

• Use• Misuse• Abuse• Intoxication• PhysicalDependence• PsychologicalDependence• Addiction

Isaddiction...

• Adisease?• Aresultofenvironment?• Aproblemofthetypeofpersoninvolved?• Aconditionedbehaviorthatbecomesselfsustaining?

Thediseasemodel• Assumesabrokenpartinthebrain• Assets

– Removesblameandstigma– Emphasizesmedicaltreatment

• Vulnerabilities– Cannotexplaindatafrommodelsorrecovery– Removesresponsibilityfrompatients

Problemswiththediseaseapproach

• Thereisavolitionalcomponenttoaddictionthatisabsentfromotherdiseasestates

• Treatmentneedstoemphasizerehabilitationratherthandrugs

• Behavioralmodelsarebetterthanlesionmodels

Addiction

• Continuedincreasingrepetitivestereotypedbehaviordespitemountingconsequencesthatdisruptsfunctioninallrealmsoflife

Buildingabehavioralmodelforaddiction

Lawofeffect• …probabilityofabehaviorcanbeincreasedordecreaseddependingonitsimmediateconsequence. Thorndyke 1913

Behaviorenvironmentalexposure environmentalresponse

positiveincrease

negativedecrease

Internal“drive” (craving)

Behavior

Reward-Reinforcement

Satiation

environmentalexposure environmentalresponse

Internal“drive” (craving)

Behavior

Reward-Reinforcement

Satiation

environmentalexposure environmentalresponse

temperamentlifeexperience

disease

Internal“drive” (craving)

Behavior

Reward-Reinforcement

Satiation

environmentalexposure environmentalresponse

temperamentlifeexperience

disease

Internal“drive” (craving)

Behavior

Reward-Reinforcement

Satiation

environmentalexposure environmentalresponse

GenesSocialconnections

ReligionOccupation

ClassGeography

Socialconventions

Timeincreaseddrugseekingbehaviorinself-administrationmodels(cocaine)

Relapsetriggers

• Drug• Stress• Environmentalcues

Majordepressionisakeyco-morbidity

Diseasefactorsthatshuntpatientstowarddysfunction

• Majordepression–uncouplestherewardsystem– increasesrelianceonescapistandavoidancecoping

– increasesthevulnerabilitytomedicationoveruse

– Increasespainsensitivityanddecreases“gating”

Behavior Reward

Addiction

Behavior Reward

Dimensionalfactorsthatshuntpatientstowarddysfunction

• Insensitivitytoconsequences• Excessivefocusonfeelings• Excessivefocusonnow• Increaseddependence• Increasedexternallocusofcontrol• Increasedtendencytofeelvictimized• (Limitedcognition)

Simplifiedmodeloftemperament

Percentofpopulation

Introversion

PunishmentavoidantFuturedirectedFunctiondirected

Extraversion

RewarddirectedPresentdirectedFeelingdirected

• Population-Disposition

Introversion-Extroversion

Stability-Instability

introversion extroversion

stable

unstable

sanguine

choleric

phlegmatic

melancholy

Behavioralfactorsthatshuntpatientstowarddysfunction

• Pre-existingaddictions– Increaseliabilitytomedicationoveruse–Decreasesocialnetworksandsupport–Decreasemotivationtogetwell–Diminishthebaselineexperienceofbeingwell

Lifestoryfactorsthatshuntpatientstowarddysfunction

• Learnedhelplessness• Lackofresources• Adisabilitysystemthatrewardsillness• Alegalsystemthatrewardsillness• Acceptanceofillnesslifestyle• Rolemodelingofselfindulgenceandcomfort• Lackofrolemodelingofmeaningfulsacrificeandacceptanceofdiscomfort

Experience

Meaning

Assumption

Behavior

Socialfactorsthatincreaseaddictions

• Generalbeliefthatonlyaddictsgetaddicted• Generalbeliefthatprescribeddrugsaresafe• Generalbeliefthatopiatesarenotaddictiveinchronicpainsufferers

• Generalbeliefthatmarijuanaisnotaddictive• Painisavitalsign• Patientsatisfaction• Patientsarecustomers

Increasedpatientsatisfactioncorrelateswithincreasedmortality

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least"sa.sfied"

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all"pa.ents"

pa.ents"in"good"health"

The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Fenton JJ, Jerant AF, Bertakis KD, Franks P. Arch Intern Med. 2012 Mar 12;172(5):405-11.

Accidentaldeathfromdrugoverdose1960-2010

Coreelementsofaddictiontreatment

• Conversion• Detoxification• Rehabilitation

– GROUP

• Treatmentofco-morbidpsychiatricconditions• RelapsePrevention

Conversion

• Confrontationwithasmile(motivationalinterviewing)

• PhysicianGoalsvs.PatientGoals– QualityofLife– Longevityvs Comfort– Function

• TreatmentContract

RoleInduction

• Describetheroleofthedoctorandthepatient

• Explanationofthediagnosisandgoalsoftreatment

• Firmlimitscombinedwithadvocacy• Focusonproblemsinthepatient’slife• Focusonbehaviorandrehabilitationandawayfromfeelings

ConfrontbehaviorMyfavoritecognitivebehavioralconfrontations

Can’tmeanswon’tNeedmeanswantThinkmeansfeel“Ican’tgetoutofbedtoday”“Whatifthebedwasonfire?”“Well,thenIcould.”“Thenyoudon’tmeancan’t,youmeanwon’t.”“Oh,fine,trickme.”

Detoxification

• Stopthebehavior• Preventwithdrawal• Diminishcraving• Treatpotentialaccompanyingdisorders

– Wernicke-Korsakoff– Endocarditis– HIV

Pharmacologictreatmentforwithdrawal

• ActiveTapers• Suppressionofspecificsymptoms

– Clonidine– Dicyclomine (Bentyl)anticholinergics– NSAID’s– Methocarbamol (Robaxin)– Antihistamines

Rehabilitation

• Damagecontrol– Social,occupationaland

familyintervention

• Environmentalchange– Peopleplacesandthingsthat

aretriggers– Structure

• Extinguishthehabit• Prescribeanewprogram

• Occupational– Vocational– Educational

• Social• Physical• Psychological

AdjunctivePharmacotherapy

• TreatmentofPsychiatricComorbidity• SubstitutedAddiction• Blockadeofreinforcement• Aversiveconditioning• Drivesuppression• Symptomatictreatmentforwithdrawal

Adjunctivepharmacotherapyforopiateaddiction

• Substitutedopiatemaintenance-MethadoneandBuprenorphine

• Blockadeofreinforcement-Naltrexone– Decreasedreinforcementforopiateuse– Decreasedhighriskopiateuse– Decreasedcriminalbehavior– Decreaseduseofopiatestomanipulatefeelings

– Increasedclinicvisitadherence

Relapseprevention

• Ongoingtreatment• Externalmonitor• Acommunityofrecoveringpeople• 12stepprograms

TreatComorbidConditions

• Treatmooddisorders– Medicationandtherapy

• AttendtoLifeStory– Psychotherapyandremoralization– Mobilizesocialsupports

• Managetemperament– Practicalsuggestionsanddirectiveadvice

Thankyou

GlennJTreismanMDPhD