Bench to Bedside: From the Science to the Practice of Addiction Medicine

Transcription

1 Bench to Bedside: From the Science to the Practice of Addiction Medicine Petros Levounis, MD, MA Chair, Department of Psychiatry Rutgers New Jersey Medical School ADDICTION MEDICINE ACADEMY Clearwater Beach, Florida March 26, 2015

2 Outline 1. The Neurobiology of Addiction 2. Psychosocial Treatments 3. Pharmacological Treatments 4. Conclusions 2

3 1 Neurobiology of Addiction 3

4 ~

5 The Fundamental Model Biological Psychological Addiction Social Use Brain Switch 5 Olsen and Levounis, Sober Siblings, 2008.

6 2015 6

7 Three Novel Areas 1. Continuum of Illness 2. Motivational Circuitry 3. Antireward Pathways 7

8 Reward Systems GAME 1? A. A sure gain of $250. B. 25% chance to gain $1,000, 75% chance to gain nothing. Adapted from: Tversky and Kahneman, Science,

9 Reward Systems GAME 1? A. A sure gain of $ % B. 25% chance to gain $1,000, 16% 75% chance to gain nothing. Adapted from: Tversky and Kahneman, Science,

10 Antireward Systems GAME 2? A. A sure loss of $750. B. 25% chance to lose nothing, 75% chance to lose $1,000. Adapted from: Tversky and Kahneman, Science,

11 Antireward Systems GAME 2? A. A sure loss of $ % B. 25% chance to lose nothing, 87% 75% chance to lose $1,000. Adapted from: Tversky and Kahneman, Science,

12 MATHEMATICS GAME 1 25% % % % GAME 2 25% % % %

13 HUMAN NATURE People avoid risks to ensure gains (even small gains). People take risks (even big risks) to avoid definite losses. Psychology trumps probability. 13

14 2 Psychosocial Treatments 14

15 1 st Wave: Psychoanalysis 1. Psychoanalysis works for all treatable mental illness. 2. Psychoanalysis does not work for addiction. 3. Therefore, addiction cannot be treated. 15

16 2 nd Wave: Boot Camps The prototype, Synanon, was founded in California in 1958 to address heroin addiction. The goal was to: Ø break down defenses, Ø bust through denial, and Ø reshape the addict s personality. 16

17 The Frying Pan 17 Volkow et al, J Neuroscience, 2001

18 3 rd : The Kitchen Sink Approach 1. Mutual Help Groups (12-step) 2. Cognitive Behavioral Therapy 3. Family Therapy 4. Primary Care Services 5. Mental Health Services 6. Aftercare Nunes, Selzer, Levounis, Davies, Substance Dependence and Co-Occurring Psychiatric Disorders,

19 Mutual Help 19

20 Attitudes and Perceptions MEDICAL STAFF 1. Housing 2. Gov t Services 3. Medical Services 4. Outpatient Tx 5. Job 6. Community 7. Trusting People 8. Inner peace 9. God 10. Spirituality 11. AA PATIENTS 1. Inner peace 2. God 3. Medical Services 4. AA 5. Housing 6. Spirituality 7. Outpatient Tx 8. Community 9. Gov t Services 10. Trusting People 11. Job What Medicine Thinks Patients Think 1. Housing 2. Outpatient Tx 3. Medical Services 4. Job 5. Trusting People 6. AA 7. Inner Peace 8. Community 9. Gov t Services 10. Spirituality 11. God 20 Goldfarb, Am J Drug Alcohol Abuse, 1996.

21 4 th : Motivational Interviewing (MI) Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, Graphic by Lukas Hassel. 21

22 5 th : Mentalization Between stimulus and response there is a space. In that space is our power to choose our response. In our response lie our growth and our freedom. Viktor E. Frankl Frankl V, Man s Search for Meaning,

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24 And Back to Psychodynamics % reporting any substance use disorders Only same-sex Mostly same-sex Equally both sexes Mostly other sex Only other sex * 11.4 *** * 9.6 *** 13.2 Ref Women Men *p<0.05, ***p<.001 based on logistic regression analysis adjusted for race, age, educational level, personal income, employment status, relationship status, health insurance status, geographic location, MSA, age at alcohol onset, and family history of AOD problems. Reference group was heterosexual group. 24 Courtesy of Sean McCabe, PhD.

25 3 Pharmacological Treatments 25

26 The Prescription Opioids Epidemic: The Root of the Disaster 26 Porter and Jick, N Engl J Med, January 10, 1980.

27 Chronic Non-Cancer Pain 27

28 Admissions: 1999 Primary non-heroin opioid admission rates (per 100,000) 28

29 Admissions: 2001 Primary non-heroin opioid admission rates (per 100,000) 29

30 Admissions: 2003 Primary non-heroin opioid admission rates (per 100,000) 30

31 Admissions: 2005 Primary non-heroin opioid admission rates (per 100,000) 31

32 Admissions: 2007 Primary non-heroin opioid admission rates (per 100,000) 32

33 Admissions: 2009 Primary non-heroin opioid admission rates (per 100,000) 33

34 Unintentional Drug Poisoning Deaths United States: Death rate per 100, Heroin Cocaine 1 0 Year '70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 National Vital Statistics System, 34

35 Unintentional Drug Poisoning Deaths United States: Alcorn, The Lancet, June 5,

36 Addiction Strategies Ø Agonists: Methadone Nicotine Replacement Ø Partial Agonists: Buprenorphine Varenicline Ø Antagonists: Naltrexone Levounis and Herron, The Addiction Casebook,

37 The Ceiling Effect 100 % Efficacy Full Agonist (Methadone) Partial Agonist (Buprenorphine) Antagonist (Naloxone) Log Dose of Opioid Adapted from: Renner and Levounis, Office-Based Buprenorphine Treatment of Opioid Dependence,

38 4 Conclusions 38

39 1. Addiction hijacks the pleasure/reward and anti-reward pathways of the brain, as well as the person s internal motivation. 2. Cognitive Behavior Therapy, mutual help groups, and Motivational Interviewing revolutionized addiction treatment. 3. In 2015, buprenorphine is the first line treatment of opioid use disorder. 39

40 Thank you NJMS.Rutgers.edu/Psychiatry 40