Alcoholism and Addiction

The Progression of the Disease

Charles Odell, MSW, MAC, LCAS

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Substance Use in the USA

30% of adult Americans have had an alcohol use disorder at some point in their lives. 50% of adult Americans have a family history of alcohol use disorders.

40% of all hospital beds (excluding beds used by maternity and intensive care) are being used to treat conditions related to alcohol consumption.

Between 48% and 53% of all adults in the US have used marijuana in their lifetime. 36% of high school seniors used marijuana (at least once) in 2017.

More than 7.5 million children in America live in a household where at least one parent has an alcohol use disorder.

Alcohol use disorders are the 3rd leading lifestyle-related cause of death in the U.S.

National Council on Alcoholism and Drug Dependence

JAMA Psychiatry

National Institute on Alcohol Abuse and Alcoholism

Substance Use in the USA

Substance use disorders contribute significantly to illness in each of the top two causes of death: heart disease and cancer.

1 in 142 U.S. citizens were confined in jail or prison in 2017. Alcohol is a factor in 40% of all violent crimes: rape, sexual assault, robbery, aggravated and simple assault.

In 2017, 10,874 people were killed in alcohol-impaired driving crashes in the U.S. That’s 29% of all the fatal motor vehicle crashes in the US.

Among Mecklenburg County arrestees under the age of 21, 53% - 74% tested positive for some type of drug (2003 - 2011) other than alcohol.

Alcohol use during pregnancy is the leading preventable cause of birth defects and developmental disabilities (i.e. fetal alcohol syndrome).

National Council on Alcoholism and Drug Dependence

Centers for Disease Control and Prevention

National Highway Traffic Safety Administration

Charlotte-Mecklenburg Drug Free Coalition US Bureau of Justice Statistics

Vaping As of October 22, 2019, 1,604 cases of e-cigarette or vaping product use

associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory.

THC vaping products called Dank Vapes are linked to many of the cases of lung illnesses.

The Cost Substance use disorders cost the American economy an estimated $740

billion per year in lost productivity, health care expenditures, crime, motor vehicle crashes and other conditions.

Untreated substance use disorders are more expensive than heart disease, diabetes and cancer combined.

Beyond the financial cost is the cost to individuals, families and society: increased crime and homelessness, family dysfunction, social problems (unemployment, violence, lost productivity), medical problems (alcoholic hepatitis, cirrhosis, HIV AIDS, hepatitis C, fetal alcohol syndrome, cardiovascular problems, gastrointestinal problems) psychiatric problems (depression, anxiety, suicides) and unintentional injuries.

Deaths from overdoses. Overdose deaths are now the leading cause of preventable deaths in the US.

Centers for Disease Control and Prevention

National Institute on Drug Abuse National Safety Council National Center for Health Statistics

The Opioid Epidemic

Drug Overdose Deaths

In 2017, more than 70,237 drug overdose deaths occurred in the United States, more than any previous year on record and 9.6% higher than in 2016. 67.8% involved opioids and 41% involved synthetic opioids (Fentanyl).

More Americans died from drug overdoses in 2017 than were killed in the entirety of the Vietnam War.

In North Carolina, drug overdose deaths increased faster in 2017 than every other State in the nation but one (Nebraska). There was a 22.5% increase in drug overdose deaths in 2017 compared to 2016.

In 2016, Mecklenburg County had the highest number of heroin-related deaths and the highest number of Fentanyl related deaths in the State.

NC Office of the Chief Medical Examiner

Centers for Disease Control and Prevention

National Institute on Drug Abuse

Heroin Purity and Price

Purity (average street heroin)

1981 - 10%

2011 - 32%

2018 - 32%

Price per gram (pure heroin)

1981 - $3260

2011 - $500

2018 - $75

Fentanyl Fentanyl is a synthetic opioid and is much more powerful

than heroin. It is used for the treatment of severe, chronic pain.

Fentanyl Fentanyl 50 times stronger than heroin.

In the US, overdose deaths from Fentanyl increased 540% from 2014 to 2016. Many Fentanyl analogues (i.e. Carfentanil, Lofentanil) are 10,000 - 20,000 times stronger than morphine.

Lethal Doses of Carfentanil, Fentanyl and Heroin

Fentanyl and Carfentanil

2mg is a lethal dose of Fentanyl. 1/100 of that is a lethal dose of Carfentanil. 4 grams of Fentanyl ($16 worth) will double the strength of one kilogram (1000 grams) of heroin.

Fentanyl Fentanyl is cheaper and easier to manufacture than heroin.

Fentanyl is approximately 50x stronger than heroin (100x morphine).

One kilo of heroin wholesales for approximately $50,000. ($200K RET)

One kilo of Fentanyl wholesales for approximately $4000. ($10ml RET)

4 grams of Fentanyl ($16 worth) will double the strength of one kilogram (1000 grams) of heroin.

There are approximately 66 analogues of Fentanyl (i.e. Carfentanil, Lofentanil). Many are stronger than Fentanyl.

Carfentanil (and other Fentanyl analogues) were not controlled substances in China until March 1, 2017, and until then were manufactured legally and sold openly over the Internet.

DEA – “Thousands” of clandestine labs in China.

Most Fentanyl comes from China and is purchased on the darknet.

Naloxone

Naloxone (Narcan) is a medication designed to rapidly reverse opioid overdose. It is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of opioids. It can very quickly restore normal respiration to a person whose breathing has slowed or stopped as a result of overdosing with heroin or prescription opioids.

There are three FDA-approved formulations of naloxone:

Injectable (professional training required)

Auto Injectable (Evzio)

Prepackaged Nasal Spray (Narcan) National Institute on Drug Abuse

“Getting sober was the bravest thing I’ve ever done and ever will do in my life” - Jamie Lee Curtis

Use, Abuse and Addiction

Substance use, abuse and addiction are three separate things.

Substance Use: Use of a substance without consequences.

Substance Abuse: Refers to harmful consequences of use, but without the presence of tolerance, withdrawal or a pattern of compulsive use.

Substance Addiction: A cluster of cognitive, behavioral, and physiological symptoms indicating continued substance use despite significant substance-related problems.

What is Addiction?

Many people have misperceptions about addiction.

Historically, there have been three, general, medical theories about addiction over the past century.

One theory remains currently valid according to:

(partial list) • American Medical Association

• American Psychiatric Association

• World Health Organization

• American Society of Addiction Medicine

• American Academy of Pediatrics

• National Institutes of Health

Past and Current Theories of Addiction

Physical Dependency

Symptom of an Underlying Problem

Primary Disease

First Doctor’s Opinion

Dr. Benjamin Rush, one of the signers of The Declaration of Independence, was the first member of the medical community to write about alcoholism and suggest it might be an illness. In a medical paper he wrote in 1784, Dr. Rush said he thought alcoholism was "a disease process." He offered no further clinical evidence.

The Doctor’s Opinion

All alcoholics “have one symptom in common: they cannot start

drinking without developing the phenomenon of craving. This phenomenon, as we have suggested, may be the manifestation of an allergy which differentiates these people, and sets them apart as a distinct entity.”

William D. Silkworth, MD

Medical Director

Charles B. Towns Hospital, New York, NY

1935

Alcoholics Anonymous (4th ed.), 1991, (pp. xxx). New York, NY: AA World Services. Inc.

Addiction is a Brain Disease

“A core concept evolving with scientific advances over the past decade is that drug addiction is a brain disease that develops over time as a result of the initially voluntary behavior of using drugs. (Drugs include alcohol.)

The consequence is virtually uncontrollable compulsive drug craving, seeking, and use that interferes with, if not destroys, an individual’s functioning in the family and in society. This medical condition demands formal treatment.”

ALAN I. LESHNER, Ph.D., M.S.

Former Chief Executive Officer, American Association for the Advancement of Science (2001-2015)

Former Executive Publisher, Science (2001-2015)

Former Director, National Institute on Drug Abuse (1994-2001)

AMA’s Definition of Alcoholism

“a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic.”

Morse, R. M., Flavin, D. K. (1992). The definition of alcoholism. JAMA. 268(8):1012-1014.

The Surgeon General

“Well-supported* scientific evidence shows that addiction to alcohol or drugs is a chronic brain disease that has potential for recurrence and recovery.”

“Well-supported* scientific evidence shows that substance use disorders can be effectively treated, with recurrence rates no higher than those for other chronic illnesses such as diabetes, asthma, and hypertension. With comprehensive continuing care, recovery is now an achievable outcome.”

*The Centers for Disease Control and Prevention (CDC) summarizes strength of evidence as: “Well-supported”: when evidence is derived from multiple controlled trials or large-scale population studies

Vice Admiral Vivek H. Murthy, M.D., M.B.A., former Surgeon General (2016)

Denial

A psychological defense mechanism postulated by psychoanalyst Sigmund Freud, in which a person is faced with a fact that is too uncomfortable to accept and rejects it instead, insisting that it is not true despite what may be overwhelming evidence.

Denial

Denial

If you're in denial, you're trying to protect yourself by refusing to accept the truth about something that's happening in your life.

In some cases, initial short-term denial can be a good thing, giving you time to adjust to a painful or stressful issue.

But denial has a dark side. Being in denial for too long can prevent you from dealing with issues that require action, such as a financial situation or a health crisis.

Looking in the mirror and accepting what we see can be one of the hardest things we ever do. It's especially hard when the image staring us in the face is painful or doesn't fit with how we want to see ourselves.

In Summary…

Perceptions of Addiction

Public and professional understanding of addiction as a disease has improved greatly over the past 50 years, resulting in increased treatment demand.

Addiction is accurately seen by health care providers as a chronic, relapsing and potentially fatal disease influenced by genetic and environmental factors with the target organ being the brain.

Addiction Has 3-P’s and 2-F’s

Primary: Substance addiction is a disease, not a symptom of a disease.

Permanent: Chronic

Progressive: Over time symptoms get worse, not better.

Fatal: If untreated, more people die from substance addiction than don’t.

Family: The disease affects systems as well as individuals i.e. families, organizations communities, countries.

How to Begin Recovery

Recovery begins with complete and total abstinence from all mood-altering drugs.

There is no excuse that justifies taking a drink or a drug.

How to Begin Recovery

Don’t drink or use, come to treatment, and abide by the recommendations of your group and the treatment team.

How to Begin Recovery

Go to AA/NA meetings.

Read the book “Alcoholics Anonymous” and begin working the 12 Steps with the help of a sponsor.

How to Begin Recovery

Practice HOW

Honesty

Open-mindedness

Willingness

Eric Clapton’s past includes addictions to alcohol, cocaine, prescription drugs and heroin. The arrival of his son Conor, however, gave him the motivation to attempt sobriety. It was a sobriety he maintained even after Conor’s tragic death in a 49-story fall at age 4.

“A woman came up to me after the meeting and said, ‘You’ve just taken away my last excuse to have a drink.’ I asked her what she meant. She said, ‘I’ve always had this little corner of my mind which held the excuse that, if anything were to happen to my kids, then I’d be justified in getting drunk. You’ve shown me that’s not true.’ I was suddenly aware that maybe I had found a way to turn this dreadful tragedy into something positive. I really was in the position to say, ‘Well, if I can go through this and stay sober, then anyone can.’ There was no better way to honor the memory of my son.”

“Do or do not, there is no try.” – Yoda