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.