It’s Not Just Drug Addiction!

Howard Wetsman MD DFASAMChief Medical Officer

Townsend Treatment Centers@addictiondocMD

hwetsman@contactaac.com

Let’s Start With Why

• What I want• Can it happen?

We Don’t Remember

How Will We Do It

• The Goal• “To make more recovering people now

and in the future”

• But why hasn’t this happened already?

• “Our problems, we think, are of our own making.”

Words And Names Are Important

• Imagine you’re a congressman– “Substance abuse”– “Addiction to…”– “Illness”

• Imagine you are an insurance company

• Imagine you are a patient

How Many Addictions Are There?

• DSM5 lists 10 SUDs and Gambling• The problem of “Addiction to…”• The DSM paradigm invented in 1981• ASAM’s Definition in 2011

ASAM’s Definition

• 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.

• ASAM Apr, 2011

A New System

• We need a new system based on this illness as it is in nature, not as we wish it to be

• What are the questions this new system should answer

Questions• If addiction is a disease, where’s the

broken bone?

• If addiction isn’t limited to drugs, how do we stay sober?

• If addiction is chronic, when does treatment end?

• If addiction is progressive, what hope do we have?

What’s the Drug?

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What’s the Drug?

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What’s a Drug?

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What’s a Reward?

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Let’s Play Whack-a-Mole

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Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health, Vector One: National, years 1991-1996, Data Extracted 2011. IMS Health, National Prescription Audit, years 1997-2013, Data Extracted 2014. Nicotine, EtOH, HFCS data from USDA data tables.

Let’s Play Whack-a-Mole

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Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health, Vector One: National, years 1991-1996, Data Extracted 2011. IMS Health, National Prescription Audit, years 1997-2013, Data Extracted 2014. Nicotine, EtOH, HFCS data from USDA data tables.

From NIDA

Shift Gears

• Back to the future

Silkworth - Allergy

• Allergy - “We believe, and so suggested a few years ago, that the action of alcohol on these chronic

alcoholics is a manifestation of an allergy; that the

phenomenon of craving is limited to this class and

never occurs in the average temperate drinker.”• Alcoholics Anonymous page XXVIII

Silkworth – Base State

• Base State - “They are restless, irritable, and discontented, unless they can again experience the

sense of ease and comfort which comes at once by

taking a few drinks – drinks which they see others

taking with impunity.”• Alcoholics Anonymous page XXVIII

Feedback Loop

Cue Induced Craving

GL

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Amygdala

Dopamine Tone

• Factors– Dopamine Release– Dopamine Receptor number and function– Time

What Medications Can Do

• Increase Dopamine Release• Increase Time• But we have no medication for

increasing receptors

Stress and Dopamine Receptors

Social Dominance in Monkeys: Dopamine Receptors and Cocaine Self-Administration Morgan et al, Nature Neuroscience 2002

Coincidentally, what do you get from an AA meeting?

Socially Housed

Housed in Isolation

Socially Housed

Attachment From the Spike

• Dangerous or risky behavior• Staying up late or sleeping in• Being the center of attention• Being liked• Making someone smile• Completion of a hard task• Sexual climax• Taking in food

Laviola G, et al. Risk-taking behavior in adolescent mice: psychobiological determinants and early epigenetic influence. NeuroSci and Biobehav Rev 27 (1-2): 19-31.Volkow ND, et al. Sleep Deprivation Decreases Binding of [11C]Raclopride to Dopamine D2/D3 Receptors in the Human Brain. Journal of Neuroscience 28(34): 8454-8461.Martinez D, et al. Dopamine Type 2/3 receptor availability in the Striatum and Social Status in Hjman Volunteers. Bio Psych 67 (3): 275-278.Hsu DT, et al. Response of the mu-opioid system to social rejection and acceptance. Mol Psych (20 August 2013) doi:10.1038/mp.2013.96Iwase M et al. Neural substrates of human facial expression of pleasant emotion induced by comic films: A PET study. NeuroImage, 17:758-768. Wassum KM, et al. Phasic mesolimbic dopamine signaling precedes and predicts performance of a self-initiated action sequence task. Bio Psych 71(10):846-54.Komisaruk BR and Whipple B. Functional MRI of the Brain During Orgasm in Women. Brain Research 1024.1 (2004): 77-88.Wang GJ, et al. Enhanced striatal dopamine release during food stimulation in binge eating disorder. Obesity 19(8):1601-8.

How Do We Stay Sober

• With brain definition we stop looking outside and start looking inside

• With midbrain localization we stop looking to our cortex for a solution

• Good news is, that part of the system already exists in 12-step and other recovery cultures

Outside vs Inside

• Is it about alcohol, cocaine, opiates, or is it about my seeking to feel better?

• Less focus on what I’m doing and more focus on why

• Less focus on an absolute and more focus on progress

Cortex vs Midbrain• Historically, we’ve sought ways to have

the cortex override the midbrain

• But now that we understand that the midbrain feeds the cortex we need to refocus

• Less about conscious thought and more about behavioral change to induce conscious change

• More about behaviors that keep dopamine tone normal

But We Already Knew That

• “You can’t think your way into new behaviors but you can behave your way into new thinking.”

• “Meeting makers make it.”• “We all have 24 hours”

What Never Ends?

• The goal of inpatient treatment is to create an outpatient

• The goal of outpatient treatment is to create a person in recovery

• The goal of recovery is to live long enough to die of something else

The Role of the Professional

• Intensive treatment phase• Monitoring recovery, not just drug use• Quickly step back in when needed

The Disease Progresses

• As we age we lose VTA cells and DA receptors

• If we live long enough we’ll all get addiction

• So what hope do we have?

A Lot

• Yes it progresses but so does recovery– Peeling the onion– Growing in spirit

• Give old-timers permission to get treatment

• There’s a lot we can do medically for people with good recovery and older brains

The Future

• Genetics• Microbiome• Non-medical biological brain

treatments

Peek at Genetics

The medical goal is to normalize hedonic function and suppress symptoms enough

so that the patient can hear the message of the non-pharmacologic part of

treatment

5HTNIC

The Mission

• To end addiction as a problem in America in my life time (30 years)

How to Achieve the Mission• Can’t cure it today• Get everyone with addiction into

recovery from addiction

• But 10-20% of the country has addiction which is up to 66 million people

• We aren’t going to get them all in recovery with the cottage industry we have

So We Need a New System

• Industrial in scale• Replicable• Easily taught• Addresses treatment and prevention

on both individual and societal levels

• Efficient in execution in that it doesn’t take sustained effort

The Goal

• To create more recovering people now and in the future.

– Safety– Courtesy and respect– Excellent care– Tell the world– Expand the system

Safety

• Addiction is a dangerous place to be. People have their guards up, and they need to know that they can safely let their guard down

• That means that we have to take responsibility for safety at every level of care

Courtesy and Respect

• A patient isn’t going to get as much out of treatment if they have a lowered dopamine tone. When we treat someone with less than full respect and courtesy we lower their dopamine tone

• There are enough places in the world where our patients can get their DA tone lowered

Excellent Care

• Cutting edge, state of the art, focused, individualized care in collaboration with the patient at all levels of care

Tell The World

• Why do we have accreditation?• Why not just expose our outcomes?• Tell the world what we’re doing to

attract more people who need our help as well as the interest of others who currently don’t know they can help

Expand The System

• To get more recovering people we’ll need greater ability to treat more people as they are attracted to treatment

• Between 10-20% of the population has addiction. Only about 10% of them ever get care

• What about the rest?

The Goal

• To create more recovering people now and in the future.

– Safety– Courtesy and respect– Excellent care– Tell the world– Expand the system

Our Current Challenges

• How to get people in

• How to get people to stay• How to get people to change• How to get people to accept help of

others