A New Paradigm for Recovery
University of Florida
Scott Teitelbaum, M.D.
FASAM, FAAP, Vice Chairman & Chief of Addiction Medicine
1
ASAM Definition of Addiction
 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.
 Addiction is characterized by inability to consistently abstain,
impairment in behavioral control, craving, diminished recognition of
significant problems with one’s behaviors and interpersonal
relationships, and a dysfunctional emotional response. Like other
chronic diseases, addiction often involves cycles of relapse and
remission. Without treatment or engagement in recovery activities,
addiction is progressive and can result in disability or premature
death.
Addiction is a Developmental Disease
1.8
TOBACCO
THC
% in each age to develop
first-time dependence
1.6
1.4
ALCOHOL
1.2
1.0
0.8
0.6
0.4
0.2
0.0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
Age
Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV
National Epidemiologic Survey on Alcohol and Related Conditions, 2003
Gateway Drug
Statistics
 Those aged 18-25 most likely to use illicit drugs.
 Age at which an adolescent begins to use alcohol is a
predictor of later alcohol and drug problems,
particularly if first use is before age 15.
 60 % of persons aged 18-25 have tried an illicit drug
before
 34% have tried an illicit drug in the past year
 20% have tried an illicit drug in the past month
National Household Survey on Drug Abuse, 2005
Winter, 2013: SAMHSA
 Between 2010 & 2011, non-medical use of prescription
drugs declined among young adults ages 18-25 (from
2M to 1.7M; 14%)
 Success of national efforts to address prescription
drug problem
 BUT… marijuana and heroin use increased
Access predicting introduction to use
 As to obtaining prescription opiates, >50% of 12th
graders were “given the drugs or bought them from a
friend or relative”
 Despite age group’s internet facility, number
purchasing opioids on internet was negligible
Inherent trust of prescribed drugs
 Less harmful because medically administered
 Dosage regulated by medical profession and
governmental oversight
 Purity of substance and quality control
Might Not Meet Today’s FDA
Standards
 Young adults commonly transitioning from
prescription opioids to heroin
 Availability of heroin + scarcity of Rx opiates
 Price of heroin
 2010 to 2011, heroin overdose deaths increased 47%
in one year (2,789 to 4,102) across entire age
spectrum of U.S. population
National Institute on Alcohol Abuse
and Alcoholism
 36 % of those aged 19-28 report having consumed
more than 5 drinks in a row in the preceding 2 weeks
 Hippocampal volumes were found to be significantly
smaller in those youths with an Alcohol Use Disorder
 Smaller hippocampal volumes with longer-duration
AUD
 May effect brain structures critical to learning and
memory formation
Generation Rx




18% of teens have abused Vicodin
20% tried Ritalin or Adderall without Rx
9% abused OTC cough syrup to get high
More teens had abused a prescription painkiller in
2004 than Ecstasy, cocaine, crack or LSD
 April 21, 2005. Partnership for a Drug Free America.
17th annual study of teen drug abuse.
Designer Drugs:
What’s New & Ongoing
“Its All About Sensation”
Serotonin rush
 Smell sensation is
intensified by the high,
resulting in a pleasurable
effect from the fumes
 Vicks inhalants, cough
drops, surgical masks
with med rub
Neurotoxicity of Drugs
substantia nigra
locus ceruleus
What’s happening at
the cellular level?
Designer Cannabinoids
This raising suspicion that these
products may contain unknown
chemicals that produce effects similar
to cannabinoids
 In Dec. 2008 a synthetic cannabinoid JWH-018 was
discovered in the herbal smoking blend Spice®
 Other synthetic cannabinoids: HU-210, HU-211, and JWH-073
were also discovered and are likely responsible for the
psychoactive effects in these products
Designer Cannabinoids
 Synthetic cannabinoids can produce the same or even
more powerful effects as those produced by the
cannabinoid molecules in the marijuana plant
 They also have very different molecular structures than
the plant cannabinoids
Nov. 4, 2002
19
Marijuana Perceived Risk vs.
Use
Adolescents with AUD
still appeared to have
reduced
neuropsychological
functioning after 3
weeks of abstinence
“Arrested Development”
 Normal risk-taking behaviors magnified with the
addition of a substance
 Pre-frontal cortex (responsible for logical thought,
judgment, decision making) not fully formed until mid20’s. Substance use can impair healthy brain
development
 Emotional coping skills often delayed as a result of
substance use
ADDICTION IS A DISEASE OF THE BRAIN
Like other diseases, it affects tissue function
Decreased Brain Metabolism in Drug Abuse Patient
High
Control
Cocaine Abuser
Decreased Heart Metabolism in Heart Disease Patient
Low
Healthy Heart
Sources: From the laboratories of Drs. N. Volkow and H. Schelbert
Hypofrontality in Cocaine Dependent Patients
Reduced Metabolic activity at baseline in cocaine dependent subjects
25
Drugs Attack the Prefrontal Cortex & Dependence
Consequences are related to dysfunctions in the
Prefrontal Cortex
 Unfortunately the Prefrontal Cortex is Critical for :





Decision-making
Weighing of risks vs. rewards
Assigning emotional valence to stimuli
Suppressing limbic impulses
Goal-directed behaviors
26
The Memory of Drugs
Front of
Brain
Back
of
Brain
Nature Video
Amygdala
Amygdala
not lit up
activated
Cocaine Video
The Adolescent Brain is Still Developing
Amygdalo-cortical Sprouting
Continues Into Early Adulthood
Childhood Adolescence Adult
Brain areas where volumes
are smaller in adolescents
than young adults
Sowell, E.R. et al., Nature Neuroscience, 2(10), pp. 859-861, 1999.
During Adolescence the
COGNITION-EMOTION
Connection is Still Forming
Cunningham, M. et al., J Comp Neurol 453, pp. 116-130, 2002.
Adolescent Brain
 These brain changes are relevant to adolescent
behavior
 Prefrontal cortex (PFC) is pruned and not fully
developed until mid-20’s
 Amygdala (and n.a.) show less pruning and tend to
dominate the PFC
Adolescent Brain Changes
prefrontal
cortex
These brain changes are
relevant to adolescent
behavior
 Prefrontal cortex (PFC) is
pruned; not fully developed
until mid-20’s
 Amygdala (and n.a.) show less
pruning and tend to dominate
the PFC
Ken Winters, Ph.D.
amygdala
nucleus
accumbens
judgment
reward
system
Judgment vs. Reward
Prefrontal
Cortex =
Judgment
Amygdala =
Reward
System
Nucleus
Accumbens
Ken Winters, Ph.D.
Adolescent Brain
Drugs
are
bad!
PFC
 This imbalance leads to...
 planned thinking
 impulsiveness
 self-control
 risk-taking
I like to
use
drugs!
amygdala
Ken Winters, Ph.D.
From “Oops” to Dependence
Ken Winters, Ph.D.
“Oops Phenomenon”
 First use to “FEEL GOOD”
 Some continue to
compulsively use because
of the reinforcing effects
(e.g., to “FEEL NORMAL”)
 Changes occur in the
“reward system” that
promote continued use
Ken Winters, Ph.D.
Reward System
 The reward system is
responsible for seeking
natural rewards that
have survival value
 seeking food, water,
sex, and nurturing
 Dopamine is this
system’s primary
neurotransmitter
Ken Winters, Ph.D.
Addiction Liability
 ~10% who ever use marijuana become daily users
 Conditional dependence – risk of dependence of
those who ever use substance





Marijuana
Ethanol
Cocaine
Heroin
Tobacco
9%
15%
17%
23%
32%
Age of Onset of First Alcoholic
Symptoms Among Alcoholics
Age (years)
%
10 – 14
3
15 – 19
39
20 – 24
22
25 – 30
15
30 – 34
5
35 – 40
4
Natural History of Primary Alcoholism
Age at first drink
Age at first intoxication
Age at first minor problem
Usual age of onset
Usual age of treatment entry
Usual age of death*
* Leading cause: Heart or liver disease, Cancer, Accidents, Suicide
Years
12-14
14-18
18-25
23-33
40
55-60
Biological
The processes
that initiate and
maintain
alcoholism are
regulated by
interactions
among nerve
cells in the brain.
Socio-cultural
Influences susceptibility
to drug usage
Psychological
Environmental
NIH/NIDA
42
Cannabis Abuse and the
Adolescent Brain
Epidemiology
• Marijuana is the most widely used illicit drug both in the
U.S. & world-wide
• More than 75 million (over 34%) of Americans 12 years
or older have tried it at least once & almost 19 million
have used it in the past year
• Average age of 1st use has been declining:
- 12-17 year olds – 13.6 years
- 18-25 year olds – 16 years
• While most discontinue marijuana by their mid-20’s, a
subset maintain daily, long-term use
Marijuana- Potency
D.E.A. Seizure Data
Marijuana- Chronic Effects
 Behavioral- “Amotivational syndrome”
 Cognitive- impaired memory/attention
 Psychiatric- rare but real permanent psychosis (likely
“flips” those predisposed)
 Respiratory- cancer, COPD
 Cardiovascular- HTN, tachycardia, MI
 Decreased Immunity
 Teratogenicity- unknown extent of fetal neurotoxicity
 Reproductive- decreased testosterone, sperm
count/motility; inhibits prolactin, LH, GH
Medical Utility of Marijuana
 Some efficacy shown in many areas
 However no studies are available comparing
marijuana to best known available treatments
 Also, smoking as a delivery mode is undesirable
because of toxicity and variability in dosing
CANNABIS AND THE BRAIN
 Increased risk of schizophrenia
 Reduced Thalamus size
 Decreased IQ
 Decreased efficiency of executive function
 Hyperactive reward centers
Relation Between Marijuana
& other Drug Use
• Early age of onset is a major predictor both of continued frequent
marijuana use & of likelihood of using other drugs (Denenhardt, et al.
2001, Lynsky, et al. 2003)
• The increased potency of marijuana may make the brain less
responsive to endogenous cannabinoids. This may be especially
marked in the still developing adolescent brain
• Combination of earlier onset & stronger marijuana may increase
anxiety & apathy in teens & make other drug use more attractive
• Twin studies found early marijuana users had increased rates of other
drug use and problems later on; odds of other drug use ranged from
2.1-5.2 times higher
Cannabis – most prevalent illicit drug
identified in impaired drivers
 Risk of involvement in a motor
vehicle accident (MVA) increases 2fold after cannabis smoking.
 Cannabis smoking increases lane
weaving and impaired cognitive
function.
 Critical-tracking tests, reaction times,
divided-attention tasks, and lane
position variability all show cannabisinduced impairment.
 Combining cannabis with alcohol
enhances impairment, especially lane
weaving.
Hartman RL, Huestis MA. Cannabis Effects on Driving Skills. 2013; 59(3): 478-492.
Marijuana Use Linked with Increased Risk of
Motor Vehicle Crashes
 Greater the amount of marijuana in a
person’s urine, the greater the risk of
a car crash
 28% of drivers who died in an accident
tested positive for non-alcohol drugs
(most commonly, marijuana)
 Marijuana use by drivers is associated
with a significantly increased risk of
being in a motor vehicle crash.
Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana Use and Motor Vehicle Crashes.
Epidemiologic Reviews. Advance Access published October 4, 2011.
USER PROFILE
 Users typically start in late teens
 Use peaks in 20’s
 Use dramatically declines with association of starting
families and careers
 10% will become daily users
 20-30% will become weekly users
Treatment of Young Adults
 Challenges:
 YA score higher on pre-contemplation, lower on
contemplation, determination, action, motivation and
readiness for change than older adults
 Higher rates of treatment non-compliance and positive
drug-test at discharge
American Journal of Drug and Alcohol Abuse, 2003
Approaches to Treatment of the
Young Adult




Focus on the treatment readiness
Work on development of healthier coping skills
Work on improving interpersonal relationships
Treatment of underlying psychiatric conditions
(common in early use of substances)
 Family therapy essential to challenge familial patterns
and educate loved ones
Relapse Rates Are Similar for Drug
Dependence And Other Chronic Illnesses
Addiction Treatment Does Work
90
80
40
30
20
50 to 70%
50
30 to 50%
60
50 to 70%
70
40 to 60%
Percent of Patients Who Relapse
100
10
0
Drug
Type I Hypertension Asthma
Dependence Diabetes
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.
 Only 1 in 10 Americans who need treatment receive
it
 Of those that need it, approximately 95% don’t
think they do
 Of the 5% who believe they need it, 2/3 made no
effort to obtain it
Treatment
Today
 Less than 50% of those admitted to publically
funded treatment successfully completed
treatment
Acute Care Treatment
as a Revolving Door
 Of those admitted to the U.S. public treatment system in
2003, 64% were re-entering treatment including 23%
accessing treatment the second time, 22% for the third or
fourth time, and 19% for the fifth or more time
(OAS/SAMHSA, 2005).
The Prevailing Acute Care Model
 An encapsulated set of specialized service activities (assess,
admit, treat, discharge, terminate the service relationship).
 A professional expert drives the process.
 Services transpire over a short (and ever-shorter) period of time.
 Individual/family/community is given impression at discharge
(“graduation”) that recovery is now self-sustainable without
ongoing professional assistance (White & McLellan McLellan, in
press).
Treatment (Acute Care Model)
Works!
 Post-Tx remissions one one-third, AOD use decreases by 87%
following Tx, &, substance substance-related problems
decrease by 60% following Tx (Miller, et al, 2001).
 Lives of individuals and families transformed by addiction
treatment.
Treatment Works, BUT…
 POST-TREATMENT RELAPSE
 The majority of people completing addiction treatment
resume AOD use in the year following treatment (Wilbourne
& Miller, 2002).
 Of those who consume alcohol and other drugs following
discharge from addiction treatment, 80% do so within 90
days of discharge (Hubbard, Flynn, Craddock, & Fletcher,
2001).
Treatment Works, BUT …
 LOW ATTRACTION
Only 10% of those needing treatment received it in 2002
(SAMHSA, 2003) & access compromised by waiting lists
(Donovan, et al, 2001).
 HIGH ATTRITION
More than half of clients admitted to addiction
treatment do not successfully complete treatment
Treatment Works, BUT…
 LOW SERVICE DOSE
Inadequate doses of Tx contribute to risk of relapse &
future readmissions
 LACK OF CONTINUING CARE
Only 1 in 5 adult clients participated in continuing care
(McKay, 2001) and only 36% of adolescents received any
continuing care (Godley, Godley & Dennis, 2001)
Fragility of Early Recovery
 Most individuals leaving addiction treatment are fragilely
balanced between recovery and re-addiction in the hours,
days, weeks, months, and years following discharge.
 Recovery and re-addiction decisions are being made at a
time that service professionals have disengaged from their
lives, while many sources of recovery sabotage are present.
Similarities to Other Medical
Disorders
 Substance addiction comparable to asthma,
hypertension and diabetes.
 Risk of relapse highest during first 3-6 months.
 Length of time in treatment is key
 Patients respond best to a combination of self help
and behavioral interventions.
 Treatment of severe cases & dual disorders requires
experts but, improves outcomes
Phase I: What are Physician Health
Programs (PHP)?
 Not treatment, disciplinary, law enforcement or licensing
organizations
 Active care managers overseeing long-term care including
drug testing
 They select and communicate with caregivers including
treatment programs, monitoring organizations and
doctors/therapists/counselors
 Physicians who enter PHP care face serious consequences
for any noncompliance including any alcohol or drug use
PHP Long-Term Drug Test Results
 Over the course of 5 years:
 78% of all physicians had
zero positive drug tests
 14% had only 1 positive drug
test
 3% had only 2 positive drug
tests
 5% had 3 or more
Lessons from the PHPS
1) Zero tolerance for any use of alcohol and other drugs
2) Thorough evaluation and patient-focused (rather than
program-focused) care
3) Prolonged, frequent random testing for both alcohol and
other drugs
4) Effective use of leverage
5) Defining and managing relapses: swift, certain and
meaningful consequences for any substance use and
noncompliance
6) Goal of lifelong recovery rooted in the 12-Step fellowships
The New HIGHER Standard
 The new paradigm has been successfully used in the criminal
justice system – a population entirely different than
physicians
New Paradigm in the CJS
 Hawaii’s Opportunity Probation with Enforcement
(HOPE) and South Dakota’s 24/7 Sobriety Project
 These programs uphold the zero tolerance
standard through drug tests and immediate, brief,
incarceration for any drug use
 Treatment is available on offender request but only
required for individuals who demonstrate the need,
using “Behavioral Triage”
 12-Step participation is optional but encouraged
HOPE Drug Test Results
 Over the course of one
year:
 61% of all HOPE
participants never had a
single positive drug test
 20% had only 1
 9% had 2
 10% had 3+
(Hawken & Kleiman, 2009)
24/7 Sobriety Drug Test Results
 Over the average 111 days
of participation:




55% never fail a test
17% fail only 1 time
12% fail only 2 times
16% fail three 3+ times
Summary of Findings
 Zero tolerance with swift, certain, and meaningful
consequences for any use of alcohol and other drugs –
contrary to reasonable assumptions – leads to lower rates of
use, higher rates of long-term success, and lower rates of
failure
 PHPs produced impressive results previously unseen
 HOPE and 24/7 Sobriety programs produced lower rates of
new crimes and lower rates of incarceration
 Use of new concept of “Behavioral Triage” – treatment is
reserved for those who need it to stay clean and sober and for
those who choose it
How Are These Programs Different?
 Old Paradigm of care management:
 Infrequent or no testing; when testing occurs in treatment, it is
scheduled
 Responses are long-delayed and unpredictable – to missed
visits, missed tests, and positive tests
 Virtually all treatment is short-term (30 days, a few months, or
maybe a year) while the substance use disorders last for
lifetimes
 The 12-Step programs are underused or not used at all in many
current treatment programs
Effective substance treatment
 Typically incorporates many components, each
directed at a particular aspect of the illness
 Must help the individual stop using drugs, maintain a
drug-free lifestyle, and achieve productive
functioning in the family, at work, and in society
 Need NOT be voluntary to be effective!
Wisdom of involuntary treatment
order
 21% of Americans ages 18-25 have substance use
disorder to severity requiring treatment
 96% of these addicted individuals do not perceive the
need for assistance
**Courts
provide critical access to care
What is recovery? A working definition
from the Betty Ford Institute
The Betty Ford Institute Consensus
Panel
There is an unknown but very large number of individuals who have
experienced and successfully resolved dependence on alcohol or
other drugs. These individuals refer to their new sober and
productive lifestyle as “recovery.” Although widely used, the lack of a
standard definition for this term has hindered public understanding
and research on the topic that might foster more and better
recovery-oriented interventions.
To this end, a group of interested researchers, treatment providers,
recovery advocates, and policymakers was convened by the Betty
Ford Institute to develop an initial definition of recovery as a starting
point for better communication, research, and public understanding.
Recovery is defined in this article as a voluntarily maintained lifestyle
composed characterized by sobriety, personal health, and citizenship.
This article presents the operational definitions, rationales, and
research implications for each of the three elements of this definition.
Journal of Substance Abuse
Treatment 2007; 33: 221-228.
The Betty Ford Institute Consensus Pane (Dr Gold was a member of this panel )
Journal of Substance Abuse Treatment , 2007; 33:221-228.
Recovery = a voluntarily maintained
lifestyle characterized by:
 Sobriety
 Early (1-11 months)
 Sustained (1-5 years)
 Stable (> 5 years)
 Personal health




Physical
Mental
Social
Spiritual
 Citizenship


“Giving-back”
Quality of life
While science has taught us that
addiction is a hijacking of the
brain, recovery must involve
healing of the heart and the soul.
Recovery
Normal
Drug Use Addiction
Treatment
The Great Challenge
For Addiction Treatment in 21st Century
To Integrate:
Addiction Medicine, Psychiatry and Spirituality
in the Treatment of Substance Use Disorders.
Challenges



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


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Increasing Rx misuse
Younger age of onset of use
More MJ smoking youth
Poly Drug, alcohol users teens
Dual Disorders
MDs role in Rx misuse
Aging Floridians and Addictions
Health Providers-MDs role in failure to Dx
ED-ERs role in failure to DX and intervene