The Chronic Disease of Addiction Evidence and Lessons from Practice Laura G. Kehoe, MD, MPH Medical Director, MGH Substance Use Disorders Unit Bridge Clinic Massachusetts General Hospital Assistant Professor of Medicine, Harvard Medical School
Disclosures I have the following relevant financial relationship with a commercial interest to disclose Guest lecture honoraria Reckitt Benckiser
Objectives Review of chronic, relapsing model of addiction Comparison with other chronic diseases Lessons from practice Lessons from patients
Addiction is Irrational Primary, chronic brain disease characterized by compulsive drug seeking and use despite harmful consequences Involves cycles of relapse and remission 40-60% genetic Without treatment addiction is progressive and can result in disability or premature death American Society of Addiction Medicine. April 12, 2011. www.asam.org NIDA. August, 2010. http://www.drugabuse.gov/publications/science-addiction
Addiction is a Developmental Disease
Childhood Dreams and Aspirations
Acute Care Model As We Know It overdose relapse detox detox relapse overdose Treatment
Can You Guess?
Circuits Involved in Addiction NIDA
Bmax/Kd DA D2 Receptors (Ratio Index) Dopamine D2 Receptors are Lower in Addiction 4.5 4 Normal Controls Cocaine Abusers Cocaine 3.5 3 2.5 Meth 2 1.5 15 20 25 30 35 40 45 50 Alcohol 3.2` 3 2.8 2.6 2.4 2.2 2 1.8 Heroin 20 25 30 35 40 45 50 control addicted Volkow et al., Neuro Learn Mem 2002. 1.6
Withdrawal Normal Euphoria Natural History of Opioid Use Disorder Tolerance & Physical Dependence Acute use Chronic use Slide courtesy of Dan Alford, 2012
Addiction is Similar to Heart Disease Decreased Heart Metabolism in Coronary Artery Disease High Decreased Brain Metabolism in Addiction Healthy heart Diseased Heart Low Healthy Brain Diseased Brain
Functional Recovery Takes Time Normal 1 month postdetox 14 months Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001
Addiction is a Treatable Disorder NIDA. Principles of Drug Addiction Treatment. 2012. McLellan et al., JAMA, 284:1689-1695, 2000.
Comparable Relapse Rates Slide courtesy of NIDA, Drugs, Brain Behavior: the Science of Addiction
Extended Abstinence is Predictive of Sustained Recovery After 5 years if you are sober, you probably will stay that way. It takes a year of abstinence before less than half relapse Dennis et al, Eval Rev, 2007 Slide courtesy of NIDA, Drugs, Brain Behavior: the Science of Addiction
Treating a Biobehavioral Disorder Must Go Beyond Just Fixing the Chemistry Pharmacological Treatments (Medications) We Need to Treat the Whole Person! Behavioral Therapies Medical Services Social Services In Social Context Slide courtesy of NIDA, Drugs, Brain Behavior: the Science of Addiction
Stacey Stacey is a 43 yof with severe OUD, remote cocaine use disorder, tobacco use disorder, COPD with recurrent pneumonia, marital discord, DCF involvement, trauma. Starts Suboxone with stabilization at 20 mg daily eventually Engaged and in remission x 12 mo, reunited with children, working Needs lung biopsy, makes it through with increase Suboxone and support Rx Tramadol from surgeon - relapse Re-engages stabilizes x 9 months Cravings in setting of custody battle, Rx adjusted Stabilizes with increased support, stress reduction, tx of her anxiety After another year, has pelvic surgery, pain, increased anxiety increase Suboxone and supports did well Note: regarding courts
Stephen Stephen is a 40 yom with long hx IVDU heroin, trauma, short stint in the reserves, and now homelessness. My first pt on Suboxone. Immediate engagement, feels normal, gets back to classes, ongoing insomnia 12 step meetings Early refill request UTOX + cocaine, THC Missed appt due to class On nightly news holding up a CVS for OxyContin
Stephen Returned to clinic on probation Resumed Rx with shorter visit intervals, support, shorter Rx supplies, engagement in counselling, contingency mgmt, GAD treatment Engagement with VA housing Stabilizes on higher dose Suboxone and increased support Periodic relapses, each shorter Now in remission 2+ years
Relapse Requires Increased Support We label patients as not ready or non compliant We ask them to seek a higher level of care on their own, when most ill We refer them for higher level of care yet many of those programs are not evidence based, and are essentially lower level of care What would we do if a cancer survivor had a lymphoma recurrence after years of remission?
People Don t Fail Treatment. Treatment Fails People Ed Salsitz, MD Deconstruct the relapse with your patient Good people make bad decisions when SUD active Change takes time, patience and trust When diseases flare, we increase care or enlist the care of other team members. This is no different Trust is an important tool Positive reinforcement (contingency management) Competing priorities Communicate with others No one size fits all just like other diseases Diet controlled pre-diabetes, oral agents, insulin for DM Diet, exercise, statin, beta-blocker, ASA, ACE inhibitors for heart disease
Lessons Learned Listen to your patients It s hard to have an addiction Diversion happens Most have used Suboxone in the past and can do home inductions Don t get caught up in the dose- splitting hairs Don t forget about pseudo-addiction Take sleep disturbance seriously advance Suboxone Take report of cravings extremely seriously treat
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