It s Not Just Drug Addiction! Howard Wetsman MD DFASAM Chief Medical Officer Townsend Treatment Centers @addictiondocmd hwetsman@contactaac.com
Let s Start With Why What I want Can it happen?
We Don t Remember
How Will We Do It The Goal To make more recovering people now and in the future But why hasn t this happened already? Our problems, we think, are of our own making.
Words And Names Are Important Imagine you re a congressman Substance abuse Addiction to Illness Imagine you are an insurance company Imagine you are a patient
How Many Addictions Are There? DSM5 lists 10 SUDs and Gambling The problem of Addiction to The DSM paradigm invented in 1981 ASAM s Definition in 2011
ASAM s 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. ASAM Apr, 2011
A New System We need a new system based on this illness as it is in nature, not as we wish it to be What are the questions this new system should answer
Questions If addiction is a disease, where s the broken bone? If addiction isn t limited to drugs, how do we stay sober? If addiction is chronic, when does treatment end? If addiction is progressive, what hope do we have?
What s the Drug? Alcohol Consumption Over Time 30 Gallons per 10 People 25 20 15 10 5 0 1900 1915 1930 1945 1960 1975 1990 2005
What s the Drug? Nicotine Consumption Over Time Hundreds of Cigarettes per Person 50 45 40 35 30 25 20 15 10 5 0 1900 1920 1940 1960 1980 2000
What s the Drug? Nic-ETOH Dopamine Load Over Time Abstract Numbers Only for Scale 25 20 15 10 5 0 1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950
What s a Drug? Nic-ETOH Dopamine Load Nic-ETOH Dopamine Load 25 20 15 10 5 0 1940 1950 1960 1970 1980 1990 2000 2010 Year
What s a Reward? Comparison of Calories and Nic-ETOH Dopamine Load Over Time 45 40 35 30 25 Dopamine Load 1000 Cal per Person 20 15 10 5 0 1960 1970 1980 1990 2000
Let s Play Whack-a-Mole 70 1200 60 1000 50 800 40 600 30 20 400 10 200 0 1950 1952 1954 1956 1958 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 0 Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health, Vector One: National, years 1991-1996, Data Extracted 2011. IMS Health, National Prescription Audit, years 1997-2013, Data Extracted 2014. Nicotine, EtOH, HFCS data from USDA data tables.
Let s Play Whack-a-Mole 120 1200 100 1000 80 800 60 600 40 400 20 200 0 1950 1952 1954 1956 1958 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 0 Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health, Vector One: National, years 1991-1996, Data Extracted 2011. IMS Health, National Prescription Audit, years 1997-2013, Data Extracted 2014. Nicotine, EtOH, HFCS data from USDA data tables.
From NIDA
Back to the future Shift Gears
Silkworth - Allergy Allergy - We believe, and so suggested a few years ago, that the action of alcohol on these chronic alcoholics is a manifestation of an allergy; that the phenomenon of craving is limited to this class and never occurs in the average temperate drinker. Alcoholics Anonymous page XXVIII
Silkworth Base State Base State - They are restless, irritable, and discontented, unless they can again experience the sense of ease and comfort which comes at once by taking a few drinks drinks which they see others taking with impunity. Alcoholics Anonymous page XXVIII
Feedback Loop
Cue Induced Craving Amygdala GL U
Dopamine Tone Factors Dopamine Release Dopamine Receptor number and function Time
What Medications Can Do Increase Dopamine Release Increase Time But we have no medication for increasing receptors
Stress and Dopamine Receptors Socially Housed Housed in Isolation Socially Housed Social Dominance in Monkeys: Dopamine Receptors and Cocaine Self-Administration Morgan et al, Nature Neuroscience 2002 Coincidentally, what do you get from an AA meeting?
Attachment From the Spike Dangerous or risky behavior Staying up late or sleeping in Being the center of attention Being liked Making someone smile Completion of a hard task Sexual climax Taking in food Laviola G, et al. Risk-taking behavior in adolescent mice: psychobiological determinants and early epigenetic influence. NeuroSci and Biobehav Rev 27 (1-2): 19-31. Volkow ND, et al. Sleep Deprivation Decreases Binding of [11C]Raclopride to Dopamine D2/D3 Receptors in the Human Brain. Journal of Neuroscience 28(34): 8454-8461. Martinez D, et al. Dopamine Type 2/3 receptor availability in the Striatum and Social Status in Hjman Volunteers. Bio Psych 67 (3): 275-278. Hsu DT, et al. Response of the mu-opioid system to social rejection and acceptance. Mol Psych (20 August 2013) doi:10.1038/mp.2013.96 Iwase M et al. Neural substrates of human facial expression of pleasant emotion induced by comic films: A PET study. NeuroImage, 17:758-768. Wassum KM, et al. Phasic mesolimbic dopamine signaling precedes and predicts performance of a self-initiated action sequence task. Bio Psych 71(10):846-54. Komisaruk BR and Whipple B. Functional MRI of the Brain During Orgasm in Women. Brain Research 1024.1 (2004): 77-88. Wang GJ, et al. Enhanced striatal dopamine release during food stimulation in binge eating disorder. Obesity 19(8):1601-8.
How Do We Stay Sober With brain definition we stop looking outside and start looking inside With midbrain localization we stop looking to our cortex for a solution Good news is, that part of the system already exists in 12-step and other recovery cultures
Outside vs Inside Is it about alcohol, cocaine, opiates, or is it about my seeking to feel better? Less focus on what I m doing and more focus on why Less focus on an absolute and more focus on progress
Cortex vs Midbrain Historically, we ve sought ways to have the cortex override the midbrain But now that we understand that the midbrain feeds the cortex we need to refocus Less about conscious thought and more about behavioral change to induce conscious change More about behaviors that keep dopamine tone normal
But We Already Knew That You can t think your way into new behaviors but you can behave your way into new thinking. Meeting makers make it. We all have 24 hours
What Never Ends? The goal of inpatient treatment is to create an outpatient The goal of outpatient treatment is to create a person in recovery The goal of recovery is to live long enough to die of something else
The Role of the Professional Intensive treatment phase Monitoring recovery, not just drug use Quickly step back in when needed
The Disease Progresses As we age we lose VTA cells and DA receptors If we live long enough we ll all get addiction So what hope do we have?
A Lot Yes it progresses but so does recovery Peeling the onion Growing in spirit Give old-timers permission to get treatment There s a lot we can do medically for people with good recovery and older brains
The Future Genetics Microbiome Non-medical biological brain treatments
Peek at Genetics 5HT NIC The medical goal is to normalize hedonic function and suppress symptoms enough so that the patient can hear the message of the non-pharmacologic part of treatment
The Mission To end addiction as a problem in America in my life time (30 years)
How to Achieve the Mission Can t cure it today Get everyone with addiction into recovery from addiction But 10-20% of the country has addiction which is up to 66 million people We aren t going to get them all in recovery with the cottage industry we have
So We Need a New System Industrial in scale Replicable Easily taught Addresses treatment and prevention on both individual and societal levels Efficient in execution in that it doesn t take sustained effort
The Goal To create more recovering people now and in the future. Safety Courtesy and respect Excellent care Tell the world Expand the system
Safety Addiction is a dangerous place to be. People have their guards up, and they need to know that they can safely let their guard down That means that we have to take responsibility for safety at every level of care
Courtesy and Respect A patient isn t going to get as much out of treatment if they have a lowered dopamine tone. When we treat someone with less than full respect and courtesy we lower their dopamine tone There are enough places in the world where our patients can get their DA tone lowered
Excellent Care Cutting edge, state of the art, focused, individualized care in collaboration with the patient at all levels of care
Tell The World Why do we have accreditation? Why not just expose our outcomes? Tell the world what we re doing to attract more people who need our help as well as the interest of others who currently don t know they can help
Expand The System To get more recovering people we ll need greater ability to treat more people as they are attracted to treatment Between 10-20% of the population has addiction. Only about 10% of them ever get care What about the rest?
The Goal To create more recovering people now and in the future. Safety Courtesy and respect Excellent care Tell the world Expand the system
Our Current Challenges How to get people in How to get people to stay How to get people to change How to get people to accept help of others