ine) on (% Baseli Concentratio DA C

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1 Chemical Dependency Relapse Pathways Relapse Prevention Medications Understanding the how, why, where and when.

2 Acknowledgements La Hacienda Treatment Center American Society of Addiction Medicine National Institute on Drug Abuse

3 Definition of Dependency A primary, progressive biochemical, psychosocial, py,g genetically transmitted chronic disease of relapse who s hallmarks are denial, loss of control and unmanageability.

5 Natural Rewards Elevate Dopamine Output of Basal DA O % o Empty FOOD Box Feeding NAc shell Time (min) Source: Di Chiara et al. Levels ine) on (% Baseli Concentratio DA C Sample Number ScrScr BasFemale 1 Present SEX Scr Mounts Intromissions Ejaculations Scr Female 2 Present Source: Fiorino and Phillips Copulation F Frequency

6 l Release % of Basal Effects of Drugs on Dopamine Levels Accumbens AMPHETAMINE DA DOPAC HVA hr Time After Amphetamine % of Basal Release Accumbens COCAINE DA DOPAC HVA hr Time After Cocaine al Release % of Basa NICOTINE Accumbens Caudate Release % of Basal 200 Release Accumbens MORPHINE Dose (mg/kg) hr Time After Nicotine hr Time After Morphine Source: Di Chiara and Imperato

7 Dopamine Transporters in Methamphetamine Abusers 2.4 Normal Control Dop pamine Tr ransporte ers (Bmax x/kd) Normal Controls Meth Abusers Methamphetamine Abuser p < Methamphetamine abusers have significant reductions in dopamine transporters. BNL - UCLA - SUNY NIDA - ONDCP - DOE

8 Dopamine Transporters in Methamphetamine Abusers Dopa amine Tran nsporter Bmax/Kd Time Gait (seconds) Delayed Recall (words remembered) Motor Task Loss of dopamine transporters in the meth abusers may result in slowing of motor reactions. Memory Task Loss of dopamine transporters in the meth abusers may result in memory impairment. BNL/UCLA/SUNY NIDA, ONDCP, DOE

9 Dopamine D2 Receptors in Addiction Cocaine Control groups Experimental groups Meth Alcohol l Food

11 Addictions Hypothalamic Dysregulation Impacts other areas of the brain including the Prefrontal Cortex, Cingulate and Pre- cingulate Gyrus, the Hippocampus, and the Amygdala.

13 Challenge: Normal Drug Use Addiction Treatment

14 Three Major Relapse Pathways I. Cross Addicting Drugs II. People/Place/Things III. BHALT B.H.A.L.T.

15 Cross Addicting Drugs a. Chemical of choice b. Related drugs c. Tobacco d. Life long relapse pathway

16 l Release % of Basal Effects of Drugs on Dopamine Levels Accumbens AMPHETAMINE DA DOPAC HVA hr Time After Amphetamine % of Basal Release Accumbens COCAINE DA DOPAC HVA hr Time After Cocaine al Release % of Basa NICOTINE Accumbens Caudate Release % of Basal 200 Release Accumbens MORPHINE Dose (mg/kg) hr Time After Nicotine hr Time After Morphine Source: Di Chiara and Imperato

17 Cross Addicting Drugs a. Chemical of choice b. Related drugs c. Tobacco d. Life long relapse pathway

18 Chemicals of Choice Cannot be a social or recreational user Cannot use in a different form or method Cannot use just on special occasions Cannot use PERIOD

19 CossAddicting Cross-Addicting Chemicals Impact on the hypothalamus as the drug of choice Usually leads back to the drug of original dependency Life long relapse pathway

20 Pain Control ol in Addiction Opiates are high risk in addictions Non Steroidal Anti-inflammatories inflammatories are safe Some skeletal muscle relaxers are safe Physical therapy, stretching, t exercise and massages are helpful Having a target for pain control or reduction

21 Anxiety in Addictions Benzodiazepines are rarely safe to use SSRI s can be used for Anxiety Disorders Other Anti-Depressant Classes can also be helpful in Anxiety Disorders Meditation and Relaxation Techniques EXERCISE

22 Sleep in Addictions Do not recommend hypnotic agents Go to bed at the same time every night No caffeine within 6 hours of bedtime No meals within 3 hours of bedtime No exercise within 3 hours of bedtime Use the bed only for sleep.

23 Tobacco 23% of Americans are addicted to tobacco >90% of the addicted population use tobacco Tobacco Cessation MUST be encouraged Relapse rates vary from 2 times to 5 times greater in addicts who continue to use tobacco

24 People/Place/Things a. History of discovery b. Three month limit for relapse

27 BHALT B.H.A.L.T. All appear to be stress mediated Relation to the Amygdala, the H-P-A AAxis Axis, and the release of CRF Reduces with time as well

29 BHALT B.H.A.L.T. a. Boredom b. Hunger c. Anger/emotions d. Loneliness e. Tiredness

30 Relapse Prevention ention Medications I. Antabuse II. III. IV. Campral ReVia Vivitrol V. Off label

31 Antabuse a. Mechanism of action b. Dosing c. Side Effects d. Efficacy

32 Campral al a. Mechanism of action b. Dosing c. Side Effects d. Efficacy

33 ReVia a. Mechanism of action b. Dosing c. Side Effects d. Efficacy

34 Vivitrol it a. Mechanism of action b. Dosing c. Side Effects d. Efficacy

35 Off label

36 Dual Diagnosis 1. Prevalence 2. Testing 3. Treatment

37 Spiritual Component of Recovery

38 Dr. Daniel Boone La Hacienda Treatment Center d

The Biology of Addiction

The Biology of Addiction Risk factors for addiction: Biological/Genetic Family history of addiction Being male Having mental illness Exposure to substances in utero * The genes that people are born with