WSADCP Conference
Seattle, Wa.
10/18/13
Neuroscientific
Basis of Addiction &
Recovery
Darryl S. Inaba,
PharmD., CATC -V,
CADCIII
Neuroscience of Addiction & Recovery Continues
• 10:30 am Developments in Addiction Treatment
• 1:15 pm Roots of Addiction
• 2:45 pm Current Trends in Substance Abuse
3 Stops Remaining
Part II: Developments in Addiction Treatment 10:30am – 12:00pm with Break
12-1:15am
Screening, Assessment, Intervention & Treatment Resources
Darryl S. Inaba, PharmD., CATC V, CADC III Darryl S. Inaba, PharmD., CATC V, CADC III Director: Clinical and Behavioral Health Services - Addictions Recovery Center
Research and Education - CNS Productions, Inc. Medford, Oregon
NIDA: Components of Comprehensive Drug
Abuse Treatment
© 2007, CNS Productions, Inc.
Addiction still requires a self-diagnosis for
effective treatment to commence
Addiction Treatment Challenges
A. Barthwell (ONDCP), UFDS, TEDS• Awareness Gap- 76% who meet diagnostic criteria claim to have no problems (Denial)
• Motivation Gap- Only 5% who recognize their addiction problem will seek treatment
• Success Gap- 2% of those wanting and seeking treatment are unable to access it within a year, but only 50% get treatment ~on demand
• Continuity Gap- Only 25%-31% who enter treatment will complete with a + discharge
• Outcome Gap- 50% completers will remain abstinence for at least one year
Addition Pathology Quick Review of
Parts I & III of Series
Addiction Pathway Brain Circuits &
Processes Reward/Reinforcement Reward/Reinforcement (Go)(Go) [I prefer [I prefer Survival/Reinforcement]Survival/Reinforcement]
Hyperactivity then Hyperactivity then Hypoactivity Hypoactivity ControlControl (Stop)(Stop)
Impaired, dysfunctional Impaired, dysfunctional or or
disconnection of Go and disconnection of Go and StopStopBill Cohen: Overactive go, Damaged Stop Bill Cohen: Overactive go, Damaged Stop & Lack of Communication between them& Lack of Communication between them
Relapse Related Brain Circuits and Processes
Stay Stopped (Slip Decisions) Stay Stopped (Slip Decisions)
Emotional Memory (Cravings)Emotional Memory (Cravings)
Stress Hormone Cycle Stress Hormone Cycle (Hypersensitivity) (Hypersensitivity)
Stop Switch
GoSwitch
Control Circuitry = Stop Switch
•Orbital Prefrontal Cortex – Especially left ventral medial OFC
•Fasciculus Retroflexus (anterior)
•Lateral Habenula (posterior and mesocortex terminal)
Diathesis-Stress Model of Addiction & Related
Disorders• HEREDITY – Type I• ENVIRONMENTAL – Type II
Stress (esp. Trauma) & Poor Nutrition• PSYCHOACTIVE DRUG TOXICITY –
Type IIINote: each phenotype has to have
elements of the others to be activated
Assessment & Treatment of Substance-Related and
Addictive Disorders
ScreeningScreening• Last use of tobacco, alcohol, drug Last use of tobacco, alcohol, drug
(Are you interested in quitting?) (Are you interested in quitting?)
• Ever experimented with drugs?Ever experimented with drugs?
• CAGE-AID (CAGE)CAGE-AID (CAGE)
• Quantity & frequency of use?Quantity & frequency of use?
• Can you abstain from alcohol while Can you abstain from alcohol while using RX? using RX?
• S-BIRT (Screen, Brief Intervention, S-BIRT (Screen, Brief Intervention, Referral Treatment) = 68% decrease Referral Treatment) = 68% decrease illicit drug useillicit drug use
Research-Validated SUD Diagnosis and Assessment
Tools• Addiction Severity Index (ASI)• Michigan Alcoholism Screening Test
(MAST)B-MAST, MAST/AD, M-SAPS, SMAST-G
• DSM-IV-Tr, DSM-V by May 2013• CAGE-AID• 4P-Plus• TWEAK• ASAM PPC-2R (Six Dimensions)• ASSIST & NM ASSIST
TREATMENT CONTINUUM
Detoxification Initial Abstinence Long-term Abstinence Recovery ASAM 4 Levels of Treatment:
IV, III.8, III.4, III.2, II.5, II, I, 0.5, et al.
Addiction is a “tug of war” between the older Meso Cortex Survival Brain and the modern
thinking Neo Cortex Brain
Fish 500 myaCambrian Explosion
Reptiles 300 mya
Amphibians 315 mya
Mammals 220 mya
Primates 65 myaHominids 5 mya
Earth 4.5 Billion Years, Life from 4 Billion Years
PrefrontalCortex
Nucleus Accumbens
Arcuate Nucleus Ventral
TegmentalArea
Brain Reward Pathways
Dopamine
Opioid Peptides
Glutamate
Courtesy of Dr. John Hart, Portland, Oregon
Limbic Area• Role: Drive Generation (SURVIVAL)• Intervention: Pharmacotherapy
Thus, Both the Unconscious & Conscious Brain Require
Treatment Courtesy of Dr. John HartPrefrontal Cortex
• Role: Executive Function• Intervention: Counseling
Clinical Treatments Targeted for Cortical (conscious) processes of
Addiction
Clinical Interventions: Evidenced-Based & >100 yrs of Practiced-
Based Interventions• National Registry of Evidence-Based Program and Practices: SAMHSA & State
• Cognitive Behavioral Therapies: Motivational Interview/Enhancement, DBT
• Levels of Change• Individual and/or Group Counseling
(process, therapy, education, topical, open)
• Manual Driven Curricula (e.g. Matrix)• Self-Help Groups (12-Steps, et. al.)
Treatments Targeted for Sub Cortical (unconscious)
Processes of Addiction
Sub Cortical Brain Structures
i.e. ~400 vaccines, genetic therapy, pharmaco-genomics, and ~more medication treatments in developments than any other medical condition
Detox: Development of Withdrawal Management
Assessment Tools• CIWA-Ar Clinical Institute Withdrawal Assessment of Alcohol-Revised
• COWS, Clinical Opiate Withdrawal Scale• ACSA, Amphetamine Cessation
Symptom Assessment Scale• BWAS, Benzodiazepine Withdrawal
Assessment Scale• WAT-1, Withdrawal Assessment Tool
Initial Abstinence: Pharmacological Cue Extinction via naltrexone and
acamprosate
Meds for Alcohol Treatment• disulfiram (Antabuse®)
• naltrexone: (ReVia® daily or Vivitrol® injected monthly)
• acamprosate (Campral®)
• chlordiazepoxide (Librium®) or Off-Label phenobarbital, other benzodiazepine for short-term detox
• Off-Label: clonidine (Catapres®), lofexidine (Britlofex®)
• Off-Label Anti-Seizure meds: topiramate (Topamax®), gabapentin (Neurontin®)
• Misc. Off-Label: ondansetron (Zofran®), fluazenil in -Prometa, baclofen (Lioresal®), nalmefene (Revex®, Selincro®)
Meds for Nicotine Treatment
• varenicline (Chantix®)
• bupropion (Zyban®, Wellbutrin®)• Nicotine Replacement Therapies
(NRT): gum (Nicorette®), patch (OTC-Nicotrol®, Nicoderm CQ®; Rx-ProStep®, Habitrol®), spray, inhaler, and lozenge
• Off-Label: nortriptyline, clonidine
Meds for Opioid Treatment• buprenorphine (Suboxone®)
• naltrexone (Revia®, Trexan®, & Vivitrol®)
• methadone• levo-alpha-acetyl-methadol (LAAM)• Off-Label: clonidine, lofexidine• Off-Label: Rapid Opioid Detoxification
(naloxone or naltrexone with midazolam, lorazepam, clonidine, anesthetics, et al.)
• Illicit in U.S.: Ibogaine
Buprenorphine (Suboxone) Ceiling Effect
Jackson County Rx OD deaths Courtesy of Dr. Jim Shames
Suboxone more Rxed than methadone
Centers for Disease Control and Prevention
(CDC) 7/3/12Steep Rise in Methadone OD deaths in 2000s Peaked out in 2007 and now falling
Still, methadone currently accounts for almost 1/3 of U.S. Rx medication deaths
In 2011 methadone was only 2% of all pain prescriptions yet responsible for more than 30% of Rx pain medication deaths
Meds for Stimulant Treatment
Note: None FDA Approved so all are Off-Label
• Antidepressants: SSRI, TCA, bupropion• MAOI-B: selegiline• Neuroleptics: resperidone, olanzapine• Sedatives: buspirone, lorazepam• Dopaminergic: bromocriptine,
amantadine• Anti-seizures: topiramate, carbamazepine• Amino Acids: tyrosine, phenylalanine• Misc.: naltrexone, disulfiram, modafinil,
ALKS-33
Meds for Sedative-Hypnotics
Note: None FDA Approved so all are Off-Label
• Usually cross-dependent medication is used and slowly tapered to detox
• Anti-seizure medications: phenobarbital + phenytoin or carbamazepine or gabapentin
• flumazenil post detox to block cravings
• SSRI, TCA, or buspirone for anxiety and/or restlessness
Preview: Challenges to Maintenance of Continued
Abstinence • Cognitive Impairment (30-80%)
• Endogenous Craving (Allostasis)
• Environmental Triggers or Cues
• Post Acute Withdrawal Symptoms (PAWS)
• Unaddressed Mental Health Treatment Needs
Courtesy of Daniel Amen, M.D.
Marijuana Abuse
All Addictive Substances ultimately shut down brain cell activity
Right Insula Right Inferior Parietal Lobule
Similar Findings: Bando, Kenneth et al. Similar Findings: Bando, Kenneth et al. Am. J. of Psychiatry, 168(2):183-192, 2011Am. J. of Psychiatry, 168(2):183-192, 2011
Right InsulaRight Insula Right InferiorRight Inferior
Parietal LobuleParietal Lobule
Right MiddleRight MiddleTemporal GyrusTemporal Gyrus
Left Cauate/Left Cauate/PutamenPutamen
Left CingulateLeft CingulateGyrusGyrus
Courtesy of Paulus, M.P.; Tapert, S.F.; Courtesy of Paulus, M.P.; Tapert, S.F.; and Schuckit, M.A. l NIDA, Archives of and Schuckit, M.A. l NIDA, Archives of General Psychiatry, 62(7), 2005General Psychiatry, 62(7), 2005
Dopamine Depletion in Addiction = Endogenous Craving and Anhedonia
Endogenous or Intrapersonal Craving
Triggers• Boredom• Fears• Anxiety or depression• Anger/resentments• Guilt and Shame• Others:
dishonesty, exhaustion, cocky, complacent, self-pity, overconfidence, impatience
Any Negative Mood State can initiate a Craving
Reaction• HALT – Hungry, Angry,
Lonely, Tired
• RIID – Restless, Irritable, Isolated,
Discontent
• BAAD – Bored, Anxious, Angry, Depressed
Environmental or Interpersonal Triggers and
Cues• Any Sensory Input to addiction memories: visual, odor, auditory, physical withdraw, etc. – PTSD?
• Thoughts of using or of withdrawal• Other Interpersonal factors:
relationship problems, social/vocational pressures, no support system, negative life events, untreated dual diagnoses
Relapse Prevention “tool kits”• Exercise, Personal Recovery Network, Journaling, Self-
Help Groups (i.e. 12-Steps), Prayer, Artistic Expression
• Also Emotional Freedom Techniques (EMDR, Brain spotting, Tapping, Elastic Snapping)
• Yoga Breathing, Somantics, Figure 8 pacing
• Mindfulness Meditation & other Grounding Interventions including acupuncture, gardening
• Consequence Reminders (family picture, car key)
• Paradoxical Interventions (i.e. vial with emptied Librium capsules; Copenhagen can; go ahead and use but first turn your shirt inside out/wash off & reapply make-up
• What ever it takes not to initiate any action to use!
Post Acute Withdrawal Syndrome (PAWS) – episodic or
recurrent• Sleep Disturbances – insomnia, nightmares• Memory Problems – Short-term, learning
• Thought Problems – concentration, rigidity, repetitive thoughts/behaviors, abstract thinking & problem solving difficulties
• Anxiety, irritability, hypersensitivity to stress• Inappropriate emotional reactions, mood
swings
• Physical and coordination difficulties, fatigue • Syndrome persists for 3-6 months, sleep
problems maybe longer – can be up to 2 years
PAWS Treatment
• Clinical: CBT “grounding exercises”
• acamprosate for alcohol PAWS
• carbamazepine (Tegratol)
• Trazodone
• naltrexone
Co-Occurring Disorder, Dual Diagnosis, MICA
• Prevalence depends on population studied• 44% alcohol abusers and 64.4% other
substance abusers met diagnoses for at least one major psychiatric disorder.
• 29% - 34% of those in mental health treatment met diagnostic criteria for an addiction and related disorder. Regier et al., 1990; Merikangas, Stevens, & Fenton, 1996
• Recovery difficult if MH disorders are not addressed
RECOVERY The Resilient
Brain8-10 Months Rigorous Uninterrupted Treatment for Reasonable
OutcomesImplies time needed for brain to
become functionalTakes up to 2 years for greater
functioning to return
Courtesy of Nora Volkow (Volkow, Hitzmann, Wong, et al 1992
Courtesy of Nora Volkow, et al. Journal of Neuroscience, 21, 9414-9418, 2001
Dopamine Transporter Binding (DAT) Recovery in
Meth Addiction
Volkow et al. J. of Neuroscience 2001
Brain Recovery even after 7 years Methadone
and Xanax Exposure
Dr. Ken Blum’s patented: Synapta GenX, KB220Z
Neuronutrient complex “normalization” of caudate, accumbens and putumen regions of heroin addicts demonstrated by fMRI Scan
NIDA’s 13 Principles of Effective Treatment: A Research-Based Guide
• Complex but treatable disease affecting brain function and behavior +/-
• No single treatment is appropriate for all +• Must be readily available -• Attends to the multiple needs of individuals
~ • Crucial to remain in treatment for adequate
period of time -• Individual, group and other evidence-based
behavioral therapies should be employed +• Medications combined with counseling and
behavioral therapies are important -
• Service plans and treatment to be assessed continually and modified as needed +
• Evaluate & address mental health and other co-occurring disorders for best outcomes -
• Medically assisted detox is only a first step and has little impact on long-term outcomes -
• Treatment does not need to be voluntary to be effective + (by default)
• Rigorous monitoring throughout treatment for drug use may help reduce relapses -
• Disease assessment (i.e. HIV, HCV, HBV, TB) and Risk-Reduction Education a must ~+
Elements of Successful Addiction Treatment
ProgramsHuman Intervention Motivation Study (HIMS) of American Airlines and United Airlines Impaired Pilots Treatment Programs Document 87%-95% Success
Impaired Physician Treatment Programs (i.e. University of Florida) enjoy 80%-90% Success
[‘Recovery Capital’ may be the major factor]
10 Elements of Successful Addiction Treatment
ProgramsDr. Kevin T. McCauley @ CAADE 4/15/111) Start with Minimum 90 day Residential
Treatment2) Transition to Immediate Aftercare Program3) Ensure Sober-Living Environment Continuum
(Recovery Oriented System of Care)4) Mandated 90/90 Contract = 90 12-Step
Meetings in 90 days5) Automatic Plan Established for Any Slips with
goal of making each a learning opportunity
10 Elements of Successful Addiction Treatment
ProgramsContinued6) Increased Drug Testing, both UA and
breathalyzer daily, even use of remote continual alcohol meter
7) Determine Rapid or Gradual Return to Duty8) Addictionologist a Must! Monitors Treatment
Intensely also a professional case manager9) Psychoactive Medication Only Via
Established Protocols10)Established “Fun in Recovery” Activities
Recovery• Continued Abstinence
• Discovery of Natural Highs
• Recovery of neurotransmitters andof natural brain functions
• Positive lifestyles and quality of life enhancements
• Remember: Not an Event but a Process
One does not cure addiction, you treat it and manage it like any other chronic persistent medical disorder
Treatment Works!Treatment Works!Treatment Works!Treatment Works!• 3 to 5 Yrs. Continued sobriety = 50% (1yr
80%)• Decrease Crime = 75%• $7-$12 Savings for every $1 Spent • Positive results from 6-8 mo. Treatment• Coerced treatment better than voluntary• Decreased Psychiatric (40%),
Family/Social (50-60%), Medical (15-20%), Employment Problems (15-20%)
• Culturally consistent better than generic treatments Belenko, et al. 2005
•Good News! Recovery Works and the brain is resilient!
•Not so Good NewsIt takes time, several months to years to just become functional, and a bit more to enjoy life again
•Memory Protrusions Shrink with Disuse and new alternate pathways become established (“Extinction”) but addicted neurons are permanent and Recovery is a Life-Long Process!
Conclusions◆ Addiction treatment results in miraculous outcomes for those who commit to and maintain continuous recovery efforts.
◆ Developments in treatments of addiction continues to improve outcomes that improve lives and health for all.
Me at Series End
Thank You!
Darryl Inaba,
PharmD., CATC V,
CADC III
Disclosures:
Dominion Diagnostics
North Kingstown, RI;
CNS Productions
Medford, OR; J. of
Psychoactive Drugs,
San Francisco, CA
Lunch Break: Reality Bites!
Fantasy Reality!Vs.