WSADCP Conference
Seattle, Wa. 10/18/13
Neuroscientific Basis
of Addiction &
Recovery
Darryl S. Inaba,
PharmD., CATC -V,
CADCIII
Neuroscience of Addiction &
Recovery Continues
3 Stops Remaining
• 10:30 am Developments in
Addiction Treatment
• 1:15 pm Roots of Addiction
• 2:45 pm Current Trends in
Substance Abuse
Part II: Developments in Addiction Treatment
10:30am – 12:00pm with Break 12-1:15am
NIDA: Components of
Abuse
Comprehensive Drug
Treatment
Screening, Assessment, Intervention & Treatment Resources
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
© 2007, CNS Productions, Inc.
Addiction still requires a selfdiagnosis 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 (Go)
[I prefer Survival/Reinforcement]
Hyperactivity then Hypoactivity
 Control (Stop)
Impaired, dysfunctional or
disconnection of Go and Stop
Bill Cohen: Overactive go, Damaged Stop & Lack
of Communication between them
Relapse Related Brain
Circuits and Processes
 Stay Stopped (Slip Decisions)
 Emotional Memory (Cravings)
 Stress Hormone Cycle
(Hypersensitivity)
Stop Switch
Go
Switch
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 III
Note: each phenotype has to have
elements of the others to be activated
Assessment &
Treatment of
Substance-Related
and Addictive
Disorders
Screening
• Last use of tobacco, alcohol, drug
(Are you interested in quitting?)
• Ever experimented with drugs?
• CAGE-AID (CAGE)
• Quantity & frequency of use?
• Can you abstain from alcohol while
using RX?
• S-BIRT (Screen, Brief Intervention, Referral
Treatment) = 68% decrease illicit 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 mya
Cambrian Explosion
Hominids 5 mya
Primates 65 mya
Reptiles 300 mya
Mammals 220 mya
Amphibians 315 mya
Earth 4.5 Billion Years, Life from 4 Billion Years
Brain Reward Pathways
Nucleus
Accumbens
Prefrontal
Cortex
Arcuate
Nucleus
Ventral
Tegmental
Area
Dopamine
Glutamate
Opioid Peptides
Courtesy of Dr. John Hart, Portland, Oregon
Thus, Both the Unconscious &
Conscious Brain Require Treatment
Courtesy of Dr. John Hart
Prefrontal Cortex
• Role: Executive Function
• Intervention: Counseling
Limbic Area
• Role: Drive Generation (SURVIVAL)
• Intervention: Pharmacotherapy
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, pharmacogenomics, 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 (OTCNicotrol®, 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
Jackson County Rx OD Deaths
50
Number of deaths caused by prescription drug overdose
annually
45
40
35
30
25
20
15
10
5
0
2002
12
2003
14
2004
24
2005
28
2006
46
2007
35
2008
33
2009
19
Suboxone more Rxed than methadone
Centers for Disease Control
and Prevention (CDC) 7/3/12
Steep 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
All Addictive Substances ultimately shut down brain cell activity
Marijuana Abuse
Courtesy of Daniel Amen, M.D.
Right Inferior
Right Insula Right
Inferior
Right
Insula Parietal Lobule
Parietal Lobule
Courtesy of Paulus, M.P.; Tapert, S.F.;
and Schuckit, M.A. l NIDA, Archives of
General Psychiatry, 62(7), 2005
Similar Findings: Bando, Kenneth et al.
Am. J. of Psychiatry, 168(2):183-192, 2011
Right Middle
Temporal Gyrus
Left Cauate/
Putamen
Left Cingulate
Gyrus
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, SelfHelp 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 Brain
8-10 Months Rigorous Uninterrupted
Treatment for Reasonable Outcomes
Implies time needed for brain to become
functional
Takes 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 Programs
Human 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 Programs
Dr. Kevin T. McCauley @ CAADE 4/15/11
1) Start with Minimum 90 day Residential Treatment
2) Transition to Immediate Aftercare Program
3) Ensure Sober-Living Environment Continuum
(Recovery Oriented System of Care)
4) Mandated 90/90 Contract = 90 12-Step Meetings
in 90 days
5) Automatic Plan Established for Any Slips with
goal of making each a learning opportunity
10 Elements of Successful
Addiction Treatment Programs
Continued
6) Increased Drug Testing, both UA and
breathalyzer daily, even use of remote continual
alcohol meter
7) Determine Rapid or Gradual Return to Duty
8) Addictionologist a Must! Monitors Treatment
Intensely also a professional case manager
9) Psychoactive Medication Only Via Established
Protocols
10)Established “Fun in Recovery” Activities
Recovery
• Continued Abstinence
• Discovery of Natural Highs
• Recovery of neurotransmitters and
of 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!
•
•
•
•
•
•
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 News
It 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
Me at Series End
recovery efforts.
◆ Developments in treatments of
addiction continues to improve outcomes
that improve lives and health for all.
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
Vs.
Reality!