Learning Objectives. A Patient to Keep Us Company. Introduction to Addiction Medicine: Root Causes and Lived Experience 3/3/2015

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1 Introduction to Addiction Medicine: Root Causes and Lived Experience Daren Ford, LCSW, CADC II Rachel Solotaroff, MD, MCR Learning Objectives Increase knowledge and understanding of substance use Engage in addiction on a scientific level Promote a balance of both science and compassion A Patient to Keep Us Company Arthur M came to Old Town Clinic in May 2011 Referred by C-TRAIN, a hospital-to-primary care home transitions program History of alcohol dependence resulting in: Chronic Pancreatitis Insulin-dependent Diabetes Chronic Pain on Chronic Opiate Therapy Ongoing history of major depression, recurrent, moderate Had worked as networks systems analyst, now unable to work Lived with parents in affluent suburb of Portland 1

2 Arthur s Background Social, Developmental and Family History: Raised by his mother and father until his parents divorce when he was 5 years old Mother remarried, and Arthur reports having a difficult relationship with his stepfather who was angry and volatile. Denies physical abuse, but endorses emotional abuse and alienation He joined the Navy at age 18, was discharged after 2.5 years He thinks his biologic father had a drinking problem, but did not see him after his parents divorce Behavioral Health History: Reports experiencing symptoms of anxiety since childhood and depression since adolescence Began drinking alcohol and using cannabis at age 13, started using cocaine shortly there after First treatment episode was at age 18 after being arrested for breaking and entering Our First Clinic Visit Reported long struggle with alcoholism; had a year of sobriety then relapsed 3 months ago Admitted to hospital with flare of his chronic pancreatitis When I met him, had been sober for one week, had reengaged with sponsor and daily AA meetings At our initial visit, he denied every being in substance abuse treatment before, denied any aberrant behavior with opiates Had to leave prior PCP due to change in insurance Interested in staying sober, getting diabetes under control, doing whatever you need me to do He also needed a refill on his chronic opioids Exercise What are Arthur s risk factors for alcohol use disorder? For opioid use disorder? What are his chances for recovery with treatment? Without treatment? 2

3 SUBSTANCE USE DISORDERS IN THE US AND OREGON: WHERE ARE WE, AND HOW DID WE GET HERE? Substance Abuse Prevalence in US Substance Dependence or Abuse in the Past Year among Persons Aged 12 or Older: SAMHSA. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings Opioid Abuse Prevalence in US Nonmedical Use of Pain Relievers in the Past Year among Individuals Aged 12 or Older, by State: Percentages, Annual Averages Based on 2012 and 2013 NSDUHs Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2012 and

4 Opioid Misuse Grows in Oregon 2008: Oregon is 5th highest state for nonmedical use of prescription painkillers* 6.6% of persons >12 years 8.2% of persons years 17.9% of persons years highest in any US state 2013: Oregon is THE highest state for nonmedical use of prescription pain relievers: 6.4% of all persons >12 years 7.4% of persons years 15% of persons years SAMHSA- 2008, 2013 National Survey on Drug Use and Health, state level data The Spectrum of Substance Use Disorders Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older SAMHSA. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings 4

5 Alcohol Use Disorder Patterns Type 1 (A): Slower, more classic pattern of progression Low degree of novelty seeking, fighting, social complications Type 2 (B): Begins drinking at early age Often uses other drugs in combination with alcohol Experiences medical, legal, and social complications in teens and 20 s Natural History of Alcohol Dependence Natural History of Alcoholism 5

6 Natural History of Alcoholism Natural History of Alcoholism Natural History of Heroin Addiction CAP Population n = 581 Hser et al,

7 The About Half Rule About half rule usually works for estimating abstinence rates or drop in proportion using a particular drug This number is affected by: Public vs private sector Psychiatric and other problem severity Why don t more people get treatment? Why is this such a devastating disease? Policy Drivers of Substance Use Disorders and Treatment Koob, CSAM Addiction Medicine Review Course, 2014 Policy Drivers of SUD s and Treatment 7

8 Policy Drivers of SUD s and Treatment Policy Drivers of SUD s and Treatment WHAT IS ADDICTION? 8

9 ASAM Definition 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 It doesn't pay to try, All the smart boys know why, It doesn't mean i didn't try, I just never know why. Feel so cold and all alone, Cause baby, you're not at home. And when i'm home Big deal, i'm still alone. Feel so restless, i am, Beat my head against a pole Try to knock some sense, Down in my bones. And even though they don't show, The scars aren't so old And when they go, They let you know You can't put your arms around a memory Don't try, don't try You're just a bastard kid, And you got no name Cause you're living with me, We're one and the same And even though they dont show, They scars aren't so old And when they go, They let you know Mother died after birth Father left after shortly after that Died of a suspected methadone overdose (still ruling out murder) Father left him at early age Mother heroin use Step father died of cancer during childhood Supposedly murdered his partner Nancy Spungen Died 1979 of heroin overdose (mother involved) 9

10 Adverse Childhood Experiences Felitti VJ, Anda RF, Nordenberg DF, et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 14, Any repeated behavior, substance related or not, in which a person feels compelled to persist, regardless of its negative impact on his or her life and the lives of others. Gabor Mate, M.D. It is a sign, a signal, a symptom of distress. It is a language that tells us about a plight that must be understood. Alice Miller 10

11 Beautiful Tragedy 8 of 13 children Poverty Father died at age 16 Raped at knife point PTSD Intoxicated during work Divorce, foreclosure, debt, poverty, spousal abuse Died at age 32 Pinuppickspenup.com THE NEUROBIOLOGY AND BEHAVIORS OF ADDICTION 11

12 Let s Ask Arthur After meeting Arthur, I refer him to our combined addictions/chronic pain program and a full pain and function evaluation In subsequent 2 months, Arthur relapses repeatedly on alcohol and is hospitalized multiple times for pancreatitis Hospital reports mention Arthur asking specifically for IV hydromorphone, and misleading staff about opioid doses He is also noted to have crushed oral oxycodone while in the ED and mixed it with water unclear what his plans were for this concoction Is found manipulating IV to create an abscess to extend stay in hospital Exercise What reaction did Arthur s story provoke in you? What factors are driving his behavior? Koob, CSAM Addiction Medicine Review Course,

13 Koob, CSAM Addiction Medicine Review Course,

14 Reward Transmitters Implicated in the Motivational Effects of Drugs of Abuse Positive Hedonic Effects Dopamine Opioid Peptides Serotonin GABA Negative Hedonic Effects of Withdrawal Dopamine dysphoria Opioid peptides pain Serotonin dysphoria GABA anxiety, panic attacks Koob, CSAM Addiction Medicine Review Course,

15 Anti-Reward Transmitters Implicated in the Motivation Effects of Drugs of Abuse Anti-Reward Transmitters Dynorphin dysphoria CRF -- stress Norepinephrine -- stress These are ACTIVATED in amygdala and ventral striatum during withdrawal 43 Koob, CSAM Addiction Medicine Review Course,

16 46 Loss of Control Over Intake Self- Medication Escalation of Drug Intake Neuron/oligodendrocyte Death Impairment of Executive Function Prefrontal Cortex Abnormalities/ Hypofunction Initial Intake Koob, CSAM Addiction Medicine Review Course, 2012 An Addictive Behavior A way of controlling an experience through external remedies All external remedies of improving or controlling are paradoxical in nature No external remedy improves a condition without internal or external consequences 16

17 A sense of control Paradoxical remedy seeking Addictive Behavior Remedies are bi-directional in consequence Nothing is addictive within itself Gabor Mate Addictive behavior as attunement Differentiate between the disease model vs a normal response to pain Propose a paradigm shift in thinking about patients through lens of attachment and trauma 17

18 Normal Response to pain Attunement Experiential avoidance Addictive Behaviors We must acknowledge what is right about addiction, not what is wrong (Gabor Mate ) 1. A sense of control 2. A sense of fulfillment 3. Relief from real pain 4. A way to increase the threshold for tolerance When a behavior is a problem (Mate ) Compulsiveness Impairment Persistence Paramount to other ways to self remedy Seen as a way towards love and vitality Replaces genuine intimacy, compassion or honest endeavors to thrive 18

19 Addiction as a maladaptive behavior Compulsiveness Paramount Replaces intimacy Seen as way to love How behaviors manifest Attachment (Bowlby) Formed by 7 months Nearly all become attached Exclusive in formative bonds Derived from social interactions Leads to specific organizational changes behavior and brain function Secure and attuned Good enough response Sufficient Near Attentive Responsive Dependable Safe Leads to health differentiation (exploring) 19

20 Insecure Attachments and Attunement (Bloom) Unreliable Repeated failure to self sooth Exaggerated responses Neglectful Chaotic Abusive Impact of and Insecure Attachment Style (Siegal/Perry) Impact brain profoundly People are seen as source of terror, neglect or ambivalence Poor self-esteem Difficulties self-regulating Low frustration tolerance Dx: anxiety and mood disorders The question to be asking is not why the addiction. 20

21 Why the pain? (Mate ) Marginalization Racism Poverty Lack of access Adverse history Socio-economic inequality Distress of daily living Loss Physical pain When we plant a seed 21