Wisconsin Association of Alcohol and Other Drug Abuse
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  • Most new cases of drug dependence develop during adolescence. Perhaps there is something special (“sensitive”) about adolescence for developing addiction.
  • Slide 11: The reward pathway Tell your audience that this is a view of the brain cut down the middle. An important part of the reward pathway is shown and the major structures are highlighted: the ventral tegmental area (VTA), the nucleus accumbens and the prefrontal cortex. The VTA is connected to both the nucleus accumbens and the prefrontal cortex via this pathway and it sends information to these structures via its neurons. The neurons of the VTA contain the neurotransmitter dopamine which is released in the nucleus accumbens and in the prefrontal cortex (point to each of these structures). Reiterate that this pathway is activated by a rewarding stimulus. [Note: the pathway shown here is not the only pathway activated by rewards, other structures are involved too, but only this part of the pathway is shown for simplicity.]

Wisconsin Association of Alcohol and Other Drug Abuse Wisconsin Association of Alcohol and Other Drug Abuse Presentation Transcript

  • Implications for Treatment and Recovery of the ASAM Definition of Addiction Medicine Michael M. Miller, MD, FASAM, FAPA WAAODA 46th Annual Spring Conference Plenary Session Wednesday, May 23, 2012 Madison, WI
  • Michael M. Miller, MD, FASAM, FAPAmmiller@rogershospital.org Medical Director, Herrington Recovery Center (HRC) Rogers Memorial Hospital Oconomowoc, Wisconsin Associate Clinical Professor University of Wisconsin School of Medicine and Public Health Associate Clinical Professor Medical College of Wisconsin, Dept of Psychiatry & Behavioral Health Past President and Board Chair Wisconsin and American Societies of Addiction Medicine Director American Board of Addiction Medicine
  • Rogers treats children, adolescentsand adults with:•Anxiety disorders•Mood disorders•Eating disorders•Substance-use disorders 800-767-4411 rogershospital.org
  • Learning ObjectivesAt the end of this presentation attendees will be able to:2. Describe for patients and families how addiction is a disease of the brain and is “not just about drugs.”3. Assess patients for pathological pursuits of reward and relief, utilizing the ASAM Definition of Addiction and the characteristic features described therein.4. Address nicotine as an addictive drug deserving of inclusion in treatment plans for other drug addictions.
  • ASAM’s MissionThe American Society of Addiction Medicine’s mission is to:• Increase access to and improve the quality of addiction treatment;• Educate physicians (including medical and osteopathic students), other health care providers and the public;• Support research and prevention;• Promote the appropriate role of the physician in the care of patients with addiction;• Establish addiction medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of health care services, and the general public.Approved by ASAM Board, 7-2006;http://198.65.155.172/CMS/images/PDF/General/Strategic%20Plan.pdf
  • Addiction Medicine:The specialty of medicine devoted to diagnosis, treatment,prevention, education, epidemiology, research, and publicpolicy advocacy regarding addiction and other substance-related health conditions
  • How to Identify a Physician Recognized forExpertise in the Diagnosis and Treatment ofAddiction and Substance-related HealthConditions (ASAM Public Policy Statement)www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html
  • www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html• Completion of a residency/fellowship in Addiction Medicine or Addiction Psychiatry• Certification in Addiction Medicine by the American Society of Addiction Medicine (ASAM)• Subspecialty certification in Addiction Psychiatry by the American Board of Psychiatry and Neurology (ABPN)• A Certificate of Added Qualification in Addiction Medicine conferred by the American Osteopathic Association (AOA)• Board Certification in Addiction Medicine by the American Board of Addiction Medicine (ABAM)
  • Addiction is not…• Just a social problem• Just a criminal problem• Just a moral problem• Frequent intoxication, heavy use, having fun• High frequency / high quantity use• Physical Dependence
  • Addiction is…• A BRAIN DISEASE• A primary, relapsing and remitting CHRONIC DISEASE….• A PEDIATRIC DISEASE….
  • Addiction is a Developmental Disease 1.8 TOBACCO 1.6 THC ALCOHOL 1.4% in each age to develop first-time dependence 1.2 1.0 0.8 0.6 0.4 0.2 0.0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 Age Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV National Epidemiologic Survey on Alcohol and Related Conditions, 2003
  • How is it that DRUGS aredifferent from broccoli?• It’s because of what ‘drugs’ do to the BRAIN• Drugs enter the body via various routes – Oral, Intravenous, Intramuscular, Intranasal, transdermal, transbuccal, or transalveolar• Drugs that affect mood/thought/behavior cross the ‘blood brain barrier’• Drugs act on nerve cells by binding to specialized portions of the outer membrane of nerve cells
  • Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC)and in connections between OFC et al.• Addiction is use despite adverse consequences, returning to use after periods of abstinence even with previous life catastrophes, inability to control use, cognitive preoccupation, conscious and unconscious craving• It involves memory, judgment, ‘executive functions’ of planning and deciding to defer gratification• All these are Frontal Lobe functions
  • Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC)and in connections between OFC et al.
  • Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC)and in connections between OFC et al.• The site of action for reward/drug-induced euphoria is the nucleus accumbens (an oversimplification)• The site of action for addiction is interplay between the frontal lobes and the Nuc Acc, and among the Nuc Acc, the hippocampus (memory), and the amygdala (motivation) – Judgment / Evaluation – Planning – Drive (drug hunger/craving; drug seeking/use) – Recalling past experiences
  • Circuits Involved in Drug Abuse and Addiction PFC MEMORY/CONTROL ACGINHIBITORY OFC Hipp LEARNING CONTROL SCC NAc c VP Amy g REWARDMOTIVATION / DRIVE
  • Addiction ‘resides’ somewhat in the Orbitofrontal Cortex(OFC) and in other areas with connections to Reward Circuitry• The site of acute action for euphoriants is the nucleus accumbens (an oversimplification)• The site of action for the chronic, recurrent, relapsing exposure to euphoriants--as is see in addiction—is the interplay among the Nuc Acc, the hippocampus (memory; recalling past experiences), the amygdala (motivation, drive, drug hunger/craving; drug seeking/use), and the frontal lobes (judgment/evaluation, planning, delay of gratification, inhibition of urges/impulses)
  • What is Addiction?American Society of Addiction Medicine • April 2011Definition of Addiction:“Addiction is a primary, chronic disease of brain reward, motivation,memory and related circuitry. Dysfunction in these circuits leads tocharacteristic biological, psychological, social and spiritualmanifestations. This is reflected in an individual pathologically pursuingreward and/or relief by substance use and other behaviors.”
  • Dysfunction in these circuits leads to characteristic biological,psychological, social and spiritual manifestations.• Question: Why is ASAM, • Values matter as a medical organization, • Violating your own values, talking about “spirituality”? then re-establishing your values, matters.• Answer: Because the • Connectedness matters. members of the DDTAG, and of the BOD, recognize • Meaning in life matters. the multidimensional aspect • Recovery is many things, of both the disease and of including a search for recovery meaning.
  • Definition of AddictionAmerican Society of Addiction Medicine • April 2011“Addiction is characterized by inability to consistently abstain,impairment in behavioral control, craving, diminished recognition ofsignificant problems with one’s behaviors and interpersonalrelationships, and a dysfunctional emotional response. Like otherchronic diseases, addiction often involves cycles of relapse andremission. Without treatment or engagement in recovery activities,addiction is progressive and can result in disability or premature death.”
  • Downward Spiral / ProgressionAddiction(constriction –ofaffects,behaviors, socialnetwork)
  • Atrophy• Of social network – People…• Of activities / interests – Places, Things• Of emotions – Flatness, less expressive, dysthymic / alexithymic• Of rewards – Salience
  • Downward Spiral of Addiction andUpward Spiral of RecoveryAddiction Recovery(constriction –of (expansion—affects, of feelings, rewards,behaviors, social activities, socialnetwork) connections)Copyright (c)2011, Covington, Griffin, & Dauer
  • How to come out of the depths?How to RECOVER?• Re-people-ization – AA – Sponsor – Church – Social clubs – Activities with others – Family• Professional Treatment (group therapy, meet others)• Re-Connectedness
  • ASAM Public Policy Statement: Definition of Addiction (Long Version)Addiction is a primary, chronic disease of brain reward,motivation, memory and related circuitry. Addiction affectsneurotransmission and interactions within reward structures ofthe brain, including the nucleus accumbens, anterior cingulatecortex, basal forebrain and amygdala, such that motivationalhierarchies are altered and addictive behaviors, which may ormay not include alcohol and other drug use, supplant healthy,self-care related behaviors.
  • ASAM Public Policy Statement: Definition of Addiction (Long Version)Addiction also affects neurotransmission and interactionsbetween cortical and hippocampal circuits and brain rewardstructures, such that the memory of previous exposures torewards (such as food, sex, alcohol and other drugs) leads to abiological and behavioral response to external cues, in turntriggering craving and/or engagement in addictive behaviors.
  • The neurobiology of addiction encompassesmore than the neurochemistry of reward.1 The frontal cortex of the brain and underlying white matterconnections between the frontal cortex and circuits of reward,motivation and memory are fundamental in the manifestationsof altered impulse control, [and] altered judgment….
  • …and the dysfunctional pursuit of rewards (which is oftenexperienced by the affected person as a desire to “be normal”)seen in addiction--despite cumulative adverse consequencesexperienced from engagement in substance use and otheraddictive behaviors.
  • Footnote 1: The neurobiology of reward has been well understoodfor decades, whereas the neurobiology of addiction is still beingexplored. Most clinicians have learned of reward pathwaysincluding projections from the ventral tegmental area (VTA) of thebrain, through the median forebrain bundle (MFB), and terminatingin the nucleus accumbens (Nuc Acc), in which dopamine neuronsare prominent. Current neuroscience recognizes that theneurocircuitry of reward also involves a rich bi-directional circuitryconnecting the nucleus accumbens and the basal forebrain.
  • Footnote 1 (continued): It is the reward circuitry where reward isregistered, and where the most fundamental rewards such asfood, hydration, sex, and nurturing exert a strong and life-sustaining influence. Alcohol, nicotine, other drugs andpathological gambling behaviors exert their initial effects byacting on the same reward circuitry that appears in the brain tomake food and sex, for example, profoundly reinforcing. Othereffects, such as intoxication and emotional euphoria fromrewards, derive from activation of the reward circuitry.
  • Footnote 1 (continued): While intoxication and withdrawal arewell understood through the study of reward circuitry,understanding of addiction requires understanding of a broadernetwork of neural connections involving forebrain as well asmidbrain structures. Selection of certain rewards, preoccupationwith certain rewards, response to triggers to pursue certainrewards, and motivational drives to use alcohol and other drugsand/or pathologically seek other rewards, involve multiple brainregions outside of reward neurocircuitry itself.
  • Genetic factors account for about half of thelikelihood that an individual will develop addiction.Environmental factors interact with the person’s biology andaffect the extent to which genetic factors exert their influence.Resiliencies the individual acquires (through parenting or laterlife experiences) can affect the extent to which geneticpredispositions lead to the behavioral and othermanifestations of addiction. Culture also plays a role in howaddiction becomes actualized in persons with biologicalvulnerabilities to the development of addiction.
  • Addiction is characterized by2:• Inability to consistently Abstain;• Impairment in Behavioral control;• Craving; or increased “hunger” for drugs or rewarding experiences;• Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and• A dysfunctional Emotional response.
  • Footnote 2: These five features are not intended to be used as“diagnostic criteria” for determining if addiction is present ornot. Although these characteristic features are widely presentin most cases of addiction, regardless of the pharmacology ofthe substance use seen in addiction or the reward that ispathologically pursued, each feature may not be equallyprominent in every case. The diagnosis of addiction requiresa comprehensive biological, psychological, social and spiritualassessment.
  • Naqvi NH, Bechara ATrends in Neurosciences, 32:56-67, 2008“…Studies using animal models [which] have emphasized therole of subcortical systems such as the amygdala, nucleusaccumbens and the mesolimbic dopamine system…havetended to focused on externally observable aspects ofaddiction (emphasis added)”
  • The power of external cues to trigger cravingand drug use, …as well as to increase the frequency of engagement inother potentially addictive behaviors, is also a characteristic ofaddiction, with the hippocampus being important in memory ofprevious euphoric or dysphoric experiences, and with theamygdala being important in having motivation concentrate onselecting behaviors associated with these past experiences.
  • Although some believe that the difference between those whohave addiction, and those who do not, is the quantity orfrequency of alcohol/drug use, engagement in addictivebehaviors (such as gambling or spending) 3, or exposure toother external rewards (such as food or sex)…,
  • …a characteristic aspect of addiction is the qualitative way inwhich the individual responds to such exposures, stressors andenvironmental cues. A particularly pathological aspect of theway that persons with addiction pursue substance use orexternal rewards is that preoccupation with, obsession with and/or pursuit of rewards (e.g., alcohol, nicotine and other drug use)persist despite the accumulation of adverse consequences.These manifestations can occur compulsively or impulsively, asa reflection of impaired control.
  • Footnote 3: In this document, the term "addictive behaviors"refers to behaviors that are commonly rewarding and are afeature in many cases of addiction. Exposure to these behaviors,just as occurs with exposure to rewarding drugs, is facilitative ofthe addiction process rather than causative of addiction. Thestate of brain anatomy and physiology is the underlying variablethat is more directly causative of addiction.
  • Footnote 3: Thus, in this document, the term “addictivebehaviors” does not refer to dysfunctional or sociallydisapproved behaviors, which can appear in many cases ofaddiction. Behaviors, such as dishonesty, violation of one’svalues or the values of others, criminal acts etc., can be acomponent of addiction; these are best viewed as complicationsthat result from rather than contribute to addiction.
  • In addiction there is a significant impairment in executivefunctioning, which manifests in problems with perception,learning, impulse control, compulsivity, and judgment. Peoplewith addiction often manifest a lower readiness to change theirdysfunctional behaviors despite mounting concerns expressedby significant others in their lives; and display an apparentlack of appreciation of the magnitude of cumulative problemsand complications.
  • Addiction is more than abehavioral disorder. Features of addiction include aspects of a person’s behaviors,cognitions, emotions, and interactions with others, including aperson’s ability to relate to members of their family, tomembers of their community, to their own psychological state,and to things that transcend their daily experience.
  • Behavioral manifestations and complications ofaddiction, primarily due to impaired control, can include:• Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control;• Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work);
  • Behavioral manifestations and complications ofaddiction, primarily due to impaired control, can include:• Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviors;• A narrowing of the behavioral repertoire focusing on rewards that are part of addiction; and• An apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems.
  • Griffith Edwards (1976) “…as dependence advances…the individualgives priority to maintaining his alcohol intake;indeed the failure of unpleasant consequencesto deter may be a clinical indicator of the degreeof dependence.”
  • Cognitive changes in addictioncan include:• Preoccupation with substance use;• Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviors; and• The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.
  • Emotional changes in addictioncan include:• Increased anxiety, dysphoria and emotional pain;• Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and• Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).
  • The emotional aspects of addiction are quitecomplex.• Some persons use alcohol or other drugs or pathologically pursue other rewards because they are seeking “positive reinforcement” or the creation of a positive emotional state (“euphoria”).• Others pursue substance use or other rewards because they have experienced relief from negative emotional states (“dysphoria”), which constitutes “negative reinforcement.“• Beyond the initial experiences of reward and relief, there is a dysfunctional emotional state present in most cases of addiction that is associated with the persistence of engagement with addictive behaviors.
  • The state of addiction is not the same as thestate of intoxication. When anyone experiences mild intoxication through the use ofalcohol or other drugs, or when one engages non-pathologically inpotentially addictive behaviors such as gambling or eating, onemay experience a “high”, felt as a “positive” emotional stateassociated with increased dopamine and opioid peptide activity inreward circuits. After such an experience, there is a neurochemicalrebound, in which the reward function does not simply revert tobaseline, but often drops below the original levels. This is usuallynot consciously perceptible by the individual and is not necessarilyassociated with functional impairments.
  • Over time, repeated experiences with substance use oraddictive behaviors are not associated with ever increasingreward circuit activity and are not as subjectively rewarding.Once a person experiences withdrawal from drug use orcomparable behaviors, there is an anxious, agitated,dysphoric and labile emotional experience, related tosuboptimal reward and the recruitment of brain and hormonalstress systems, which is associated with withdrawal fromvirtually all pharmacological classes of addictive drugs.
  • While tolerance develops to the “high,” tolerance does notdevelop to the emotional “low” associated with the cycle ofintoxication and withdrawal. Thus, in addiction, personsrepeatedly attempt to create a “high”--but what they mostlyexperience is a deeper and deeper “low.” While anyone may“want” to get “high”, those with addiction feel a “need” to usethe addictive substance or engage in the addictive behavior inorder to try to resolve their dysphoric emotional state or theirphysiological symptoms of withdrawal.
  • Persons with addiction compulsively use even though itmay not make them feel good, in some cases long after thepursuit of “rewards” is not actually pleasurable.5 Althoughpeople from any culture may choose to “get high” from oneor another activity, it is important to appreciate that addictionis not solely a function of choice. Simply put, addiction isnot a desired condition.
  • Edgar DegasL Absinthe(The Absinthe Drinker)1875-76Musée dOrsayParis, France
  • Footnote 5: Pathologically pursuing reward (mentioned inthe Short Version of this definition) thus has multiplecomponents. It is not necessarily the amount of exposure tothe reward (e.g., the dosage of a drug) or the frequency orduration of the exposure that is pathological.
  • Footnote 5 (continued): In addiction, pursuit of rewards persists,despite life problems that accumulate due to addictive behaviors,even when engagement in the behaviors ceases to be pleasurable. Similarly, in earlier stages of addiction, or even before the outwardmanifestations of addiction have become apparent, substance useor engagement in addictive behaviors can be an attempt to pursuerelief from dysphoria; while in later stages of the disease,engagement in addictive behaviors can persist even though thebehavior no longer provides relief.
  • As addiction is a chronic disease, periods of relapse,which may interrupt spans of remission, are a commonfeature of addiction.  It is also important to recognize thatreturn to drug use or pathological pursuit of rewards isnot inevitable.
  • Clinical interventions can be quite effective in altering the course ofaddiction. Close monitoring of the behaviors of the individual andcontingency management, sometimes including behavioralconsequences for relapse behaviors, can contribute to positiveclinical outcomes. Engagement in health promotion activities whichpromote personal responsibility and accountability, connection withothers, and personal growth also contribute to recovery. It isimportant to recognize that addiction can cause disability orpremature death, especially when left untreated or treatedinadequately.
  • As is the case with other chronic diseases, the condition mustbe monitored and managed over time to:•Decrease the frequency and intensity of relapses;•Sustain periods of remission; and•Optimize the person’s level of functioning during periods of remission.
  • • In some cases of addiction, medication management can improve treatment outcomes.• In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results.• Chronic disease management is important for minimization of episodes of relapse and their impact.• Treatment of addiction saves lives †
  • Treat Addiction Save Lives© ASAM
  • Targeted Therapeutic Changes inAddiction TreatmentBEHAVIORAL CHANGES BIOLOGICAL CHANGES• Eliminate alcohol and other drug • Resolve acute alcohol and other use behaviors drug withdrawal symptoms• Eliminate other problematic • Physically stabilize the organism behaviors • Develop sense of personal• Expand repertoire of healthy responsibility for wellness behaviors • Initiate health promotion• Develop alternative behaviors activities (e.g., diet, exercise, safe sex, sober sex)
  • Targeted Therapeutic Changes inAddiction TreatmentCOGNITIVE CHANGES AFFECTIVE CHANGES• Increase awareness of illness • Increase emotional awareness• Increase awareness of negative of negative consequences of consequences of use use• Increase awareness of addictive • Increase ability to tolerate disease in self feelings without defenses• Decrease denial • Manage anxiety and depression • Manage shame and guilt
  • Targeted Therapeutic Changes inAddiction TreatmentSOCIAL CHANGES SPIRITUAL CHANGES• Increase personal responsibility • Increase self-love/esteem; in all areas of life decrease self-loathing• Increase reliability and • Reestablish personal values trustworthiness • Enhance connectedness• Become resocialized: • Increase appreciation of reestablished sober social transcendence network• Increase social coping skills: with spouse/partner, with colleagues, with neighbors, with strangers Miller, Michael M. Principles of Addiction Medicine, 1994; published by American Society of Addiction Medicine, Chevy Chase, MD
  • Traditional Targets of “Substance AbuseTreatment”• Alcohol abuse and dependence.• Sedative abuse and dependence.• Cocaine abuse and dependence.• Stimulant abuse and dependence.• Opioid abuse and dependence.• Cannabinoid abuse and dependence.• Hallucinogen abuse and dependence.• Dissociative Drug abuse and dependence.• Inhalant abuse and dependence.
  • Topics Often Not Addressed in Traditional“Substance Abuse Treatment”• Codependency• Nicotine dependence.• Pathological gambling.• Sexual compulsivity.• Compulsive overeating.• Compulsive shopping/spending/debting.• Compulsive Internet/computer game/video game playing.
  • Nicotine Addiction• Clearly, nicotine is the rewarding/reinforcing substance in tobacco• ASAM’s tag line is “Treat Addiction Save Lives”• If any addiction professional is interested in saving lives, tobacco/nicotine must be targetedDEATHS per year:• Tobacco = 440,000• Alcohol = 110,000• Opioid pills = 38,000• Other drugs = less than 20,000 (if you exclude HIV/HCV)
  • Nicotine• Acts on acetyl choline receptors, the nicotinic subtype of the A Ch receptor.• Actions• Harms – Heat – Carbon monoxide – Solids in smoke (nitrosamines and other carcinogens)• Second Hand Smoke• Third Hand Smoke
  • Addiction is characterized by2:• Inability to consistently Abstain;• Impairment in Behavioral control;• Craving; or increased “hunger” for drugs or rewarding experiences;• Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and• A dysfunctional Emotional response.
  • How is tobacco/nicotine addiction treated?• Education (groups offered by American Lung Assn, AHA)• Behavioral therapy (behavioral analysis of smoking situations/circumstances; addressing high-risk situations; changing the environment to reduce cue exposure)• Pharmacotherapy – NRT (“gum”, lozenges, patches, inhalers, nasal sprays) – Bupropion (Zyban®) or other antidepressants – Varenicline (Chantix®) – partial agonist – Clonidine
  • How has tobacco/nicotine addiction notbeen treated?• Intensive Outpatient – Multiple sessions per week – Combination of psychoeducational and psychotherapeutic groups – Group THERAPY• Family therapy• Continuing care groups (relapse prevention)• Insistence on abstinence• Monitoring of abstinence (urine cotinine levels)• 12-step approaches (they exist, but not widespread: Nicotine Anonymous is ‘the other NA’; Smokers Anonymous is ‘the other SA’)
  • What if the ASAM Definition guidedtreatment planning?• Comprehensive assessment – Age of first use, age of first regular use, problems from use, loss of control, preoccupation, ABCDE• All pathological sources of reward/relief are relevant – Could be a problem now, or could become a problem later• Insist on abstinence – Use of any substance that activates reward circuitry is dangerous in a person with this disease
  • Considering the alternative: not treattobacco/nicotine addiction concurrently?• Is it an addiction?• Is it harmful (causing dysfunction, illness, death)?• If a patient were to say “I want help for heroin and cocaine, but I want to be able to continue to smoke tobacco -- I just can’t do everything at once” – how would you react?• Does continuing to “tweak” the reward circuitry with a powerful agonist affect relapse to a person’s “drug of choice”?• Physician Health Program data.
  • Gambling Addiction (DSM-IV approach)The following are the diagnostic criteria from the DSM-IV for 312.31(Pathological Gambling):A. Persistent and recurrent maladaptive gambling behavior as indicatedby at least five of the following:1. is preoccupied with gambling (e.g., preoccupied with reliving pastgambling experiences, handicapping or planning the next venture, or thinking ofways to get money with which to gamble)2. needs to gamble with increasing amounts of money in order toachieve the desired excitement3. has repeated unsuccessful efforts to control, cut back, or stopgambling4. is restless or irritable when attempting to cut down or stop gambling5. gambles as a way of escaping from problems or of relieving adysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression).
  • Gambling Addiction (DSM-IV approach) 6. after losing money gambling, often returns another day in order to get even (“chasing” one’s losses) 7. lies to family members, therapist, or others to conceal the extent of involvement with gambling 8. has committed illegal acts, such as forgery, fraud, theft, or embezzlement, in order to finance gambling 9. has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling 10. relies on others to provide money to relieve a desperate financial situation caused by gambling B. The gambling behavior is not better accounted for by a Manic Episode. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.
  • Epidemiology• 1 – 2 % of adults• 2 – 4 % of adolescents• Most severe cases associated with the rapidity of reinforcement (IV route of drug administration is more addictive than oral route; video poker is more addictive than racetracks; OTB parlors are more addictive than in vivo)• Availability drives up exposure; exposure leads to increased rates of addiction
  • Physiology of Gambling Addiction• Causes release of dopamine in nucleus accumbens• Leads to same changes in neurophysiology as do exposure to cocaine and other stimulants• Neuroimaging studies.
  • DSM-V Gambling DisorderThe work group has proposed that this diagnosis be reclassified from Impulse-Control Disorders Not Elsewhere Classified to Substance-Related Disorderswhich will be renamed Addiction and Related DisordersA. Persistent and recurrent problematic gambling behavior as indicated byfour (or more) of the following in a 12-month period:1. needs to gamble with increasing amounts of money in order to achievethe desired excitement2. is restless or irritable when attempting to cut down or stop gambling3. has repeated unsuccessful efforts to control, cut back, or stop gambling4. is often preoccupied with gambling (e.g., persistent thoughts of relivingpast gambling experiences, handicapping or planning the next venture, orthinking of ways to get money with which to gamble)
  • DSM-V Gambling Disorder 5. gambles often when feeling distressed (e.g., helpless, guilty, anxious, depressed) 6. after losing money gambling, often returns another day to get even (“chasing” one’s losses) 7. lies to conceal the extent of involvement with gambling 8. has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling 9. relies on others to provide money to relieve desperate financial situations caused by gambling
  • DSM 5 Gambling DisorderB. The gambling behavior is not better accounted for by a Manic Episode.Course Specifiers.- Episodic- Chronic- In Remission
  • Addiction: Associated with Internet/VideoGames• Didn’t “make the cut” with DSM-V, but it came close!• Reinforcement can be rapid and repeated – Inability to consistently Abstain; – Impairment in Behavioral control; – Craving; or increased “hunger” for drugs or rewarding experiences; – Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and – A dysfunctional Emotional response.
  • Internet Use Disorder (DSM-V)This condition is being recommended for further study inSection III, which is the section of the DSM-V text in whichconditions that require further research will be included.A. Preoccupation with Internet gamingB. Withdrawal symptoms when internet is taken awayC. Tolerance: the need to spend increasing amounts oftime engaged in Internet gamingD. Unsuccessful attempts to control Internet gaming use
  • Internet Use Disorder (DSM-V)E. Continued excessive Internet use despite knowledge of negative psychosocial problemsF. Loss of interests, previous hobbies, entertainment as a result of, and with the exception of Internet gaming useG. Use of the Internet gaming to escape or relieve a dysphoric moodH. Has deceived family members, therapists, or others regarding the amount of Internet gamingI. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of Internet gaming use
  • Addiction: Associated with SexThis condition is being recommended for further study in Section III, which is the section of theDSM-5 text in which conditions that require further research will be included.Hypersexual DisorderA. Over a period of at least 6 months, recurrent and intense sexual fantasies,sexual urges, and sexual behavior in association with four or more of the following fivecriteria:(1) excessive time is consumed by sexual fantasies and urges, and by planning for andengaging in sexual behavior(2) repetitively engaging in these sexual fantasies, urges, and behavior in response todysphoric mood states (e.g., anxiety, depression, boredom, irritability)(3) repetitively engaging in sexual fantasies, urges, and behavior in response to stressful lifeevents(4) repetitive but unsuccessful efforts to control or significantly reduce these sexualfantasies, urges, and behavior(5) repetitively engaging in sexual behavior while disregarding the risk for physical oremotional harm to self or others
  • Addiction: Associated with SexThis condition is being recommended for further study in Section III, which is the section of theDSM-5 text in which conditions that require further research will be included.Hypersexual DisorderB. There is clinically significant distress or impairment in social, occupational or otherimportant areas of functioning associated with the frequency and intensity of these sexualfantasies, urges, and behavior.C. These sexual fantasies, urges, and behavior are not due to direct physiological effectsof exogenous substances (e.g., drugs of abuse or medications), a co-occurring generalmedical condition or to Manic Episodes.D. The individual is at least 18 years of age.Specify if:–In a Controlled Environment–In Remission (No Distress, Impairment, or Recurring Behavior for Five Years and in anUncontrolled Environment)Environment
  • Addiction: Associated with SexThis condition is being recommended for further study in Section III, which is the section of theDSM-5 text in which conditions that require further research will be included.Hypersexual DisorderSpecify if:–Masturbation–Pornography–Sexual Behavior With Consenting Adults–Cybersex–Telephone Sex–Adult Entertainment Venues/Clubs–Other:
  • Addiction Associated with Sex ischaracterized by:• Inability to consistently Abstain;• Impairment in Behavioral control;• Craving; or increased “hunger” for drugs or rewarding experiences;• Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and• A dysfunctional Emotional response. – Keep doing it even when it doesn’t produce positive emotion – Subcortical drive to produce experience of “reward”
  • Addiction: Associated with Pornography
  • Addiction: Associated with EatingBinge Eating Disorder (DSM-V)A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating)B. The binge-eating episodes are associated with 3 (or more) of the following:1. Eating much more rapidly than normal.2. Eating until feeling uncomfortably full3. Eating large amounts of food when not feeling physically hungry4. Eating alone because of feeling embarrassed by how much one is eating.5. Feeling disgusted with oneself, depressed, or very guilty after overeating.
  • Addiction: Associated with EatingBinge Eating Disorder (DSM-V)C. Marked distress regarding binge eating is present.D. The binge eating occurs, on average, at least once a week for 3 months.E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior and does not occur exclusively during the course Bulimia Nervosa or Anorexia Nervosa.Not called “Compulsive Overeating” by DSM-V committee.Not called “Eating Addiction.”Nothing in DSM-V re: addictive food restriction or addictive exercise
  • “Switching Addictions”?…..or is it just one illness?• Alcoholism → Sedativism• Alcoholism → cocaine, opioids, cannabinoids• Cocaine → gambling, sexual compulsivity• Obesity → Alcoholism• Alcoholism → Obesity• Bariatric Surgery → Alcoholism• Nicotine → all other drugs
  • Implications of the ASAM Definition forTreatment• A significant feature of the ASAM approach is to outline that addiction is best understood as a unitary condition: addiction is addiction.  • Addiction can involve drinking, smoking, gambling, or even purging, but the ASAM definition does not describe alcohol addiction, nicotine addiction, gambling addiction, or purging addiction as separate entities. ASAM, through the work of its Descriptive and Diagnostic Terminology Action Group, has defined “Addiction” and would discourage focus on “the Addictions.”
  • Implications of the ASAM Definition forTreatment• Whereas the DSM and ICD systems may continue to have separate diagnostic codes based on specific substances and behaviors, ASAM is suggesting the unitary approach, focusing on the internal brain processes in addiction rather than putting focus on various external sources of reward or relief. The unitary approach can also ensure that assessment and treatment are much more comprehensive, in which abstinence from all psychoactive substances would be recommended and monitoring of all potential addictive behaviors would be needed on an ongoing basis.
  • Implications of the ASAM Definition forTreatment• It is essential to ensure that health care providers, patients and their families understand that the individual with this disease is vulnerable to loss of control with engagement with other addictive substances and behaviors than the ones that led them to seek help.
  • Implications of the ASAM Definition forTreatment• While research may be done to carefully delineate inclusion and exclusion criteria for things such as “Internet addiction” or “sex addiction”, the ASAM approach would say simply that an individual has “addiction,” though it could specify the condition with terms such as “addiction associated with alcohol” or “addiction associated with gambling” or “addiction associated with hallucinogens” or “addiction associated with spending and debting.”
  • The Physiology of AddictionCertain substances have the ability to interact with thebrain’s Reward Circuitry and are thus euphoriants; they arereinforcing, and, in lab animals, self-reinforcing. They act firstby being external ligands for neuro-transmitter receptors, or bycausing release of (or otherwise altering levels of) neuro-transmitters.They hijack the reward system, and the individualcompulsively pursues these rewards instead of naturalrewards.
  • The Physiology of AddictionOnce the Reward Circuitry is turned on, there are changes inrelated brain areas or neuronal circuits, and these result in thecharacteristic manifestations of addiction [altered memory ofpast intoxication experiences, altered cue response, changesin motivation so that ‘the drug’ (can be a substance, or apathologically rewarding activity) becomes ‘the salientreinforcer,’ replacing other healthy reward]. All this contributesto preoccupation and loss of control.
  • The Physiology of Addiction• Changes in frontal lobe function (executive functioning; the inhibition of impulses to use) are key: the brain fails in efforts to inhibit the drive to obtain/use the drug to create ‘the high’.• Impairment in control and preoccupation are the key behavioral/cognitive characteristics of addiction, and have an anatomical/physiological substrate in the brain.• Relapse is intrinsic to virtually all chronic diseases; the animal model of relapse is “reinstatement” of drug use or drug preference.
  • Circuits Involved in Drug Abuse and Addiction PFC MEMORY/CONTROL ACGINHIBITORY OFC Hipp LEARNING CONTROL SCC NAc c VP Amy g REWARD MOTIVATION/ DRIVE
  • Addiction professionals and persons in recovery know thehope that is found in recovery. Recovery is available even topersons who may not at first be able to perceive this hope,especially when the focus is on linking the healthconsequences to the disease of addiction.
  • As in other health conditions, self-management, withmutual support, is very important in recovery fromaddiction.Peer support such as that found in various “self-help” activitiesis beneficial in optimizing health status and functionaloutcomes in recovery. ‡
  • Recovery from addiction is best achievedthrough a combination of self-management,mutual support, and professionalcare provided by trained and certifiedprofessionals.  
  • NIDA Principles of Drug Addiction Treatment(1999, rev 2009)1. Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased.2. No single treatment is appropriate for everyone.NIH Publication No. 09–4180
  • The Herrington Recovery Center
  • Thank you! Michael M. Miller, MD, FASAM, FAPA mmiller@rogershospital.org The Herrington Recovery Center at Rogers Memorial Hospital For more information, call 800-767-4411 or visit rogershospital.org