Cheif Presentation - Jerrold Frank Rosenbaum
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Cheif Presentation - Jerrold Frank Rosenbaum






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    Cheif Presentation - Jerrold Frank Rosenbaum Cheif Presentation - Jerrold Frank Rosenbaum Presentation Transcript

    • AgendaI. Introduction & OverviewII. The Disease of AddictionIII. Population and Risk FactorsIV. TreatmentV. Center for Addiction Medicine Initiatives 1
    • Substance Misuse: The Nation‟sNumber One Public Health Problem There are more deaths, illnesses, and disabilities from substance use than from any other preventable health condition  Of the more than 2 million deaths each year in the US, 1 in 4 is attributable to alcohol, tobacco, and illicit drug use Alcohol alone causes about 20–30% of esophageal cancer, liver cancer, cirrhosis of the liver, homicide, epileptic seizures, and motor vehicle accidents worldwide (WHO, 2002). Over 22.6 million Americans have problem with alcohol or other drugs  More than half of all families in the US has or has had a family member suffering from alcohol dependence (NIAAA, 2005)  Alcohol use is involved in 25-50% of suicides  37% of those with alcohol dependence and 53% of those with dependence on an illicit drug have another psychiatric illness 2
    • Economic Burden The economic burden associated with alcohol misuse alone is approaching $200 billion annually, far exceeding the cost associated with other medical conditions such as cancer ($107 billion) and heart disease ($96 billion). When combined with other drugs the economic burden is close to $400 billion annually.Gruel and Rehm. 2003 3
    • MGH Facts/Figures At MGH Outpatient Addiction Services, approximately 2 out of 3 patients have co-occurring mental health and substance use disorder diagnoses Inpatients with an SUD primary or secondary diagnoses had a LOS of 2.5 days longer than those without Patients with alcohol use issues comprise 5% of all ED visits, but 7.2% of ED bed hours, or 3 beds in any 24 hour period  32% admitted, compared to 26% of other patients 4
    • Starkly ReducedDopamineReceptorExpressionObserved in BrainReward Centers inthe Striatum 5
    • Reduced D2 Receptor Expression ExperimentallyInduced by Social Stress and Correlation withCocaine Self Administration Morgan, et al., 2002, Nat Neurosci 6
    • 7
    • 3-D Iso-surface Representation of Amygdala in Cocaine Addiction Showing 23% Volume Reduction Superior Right Amygdala Right Lateral Ventricle = red Posterio Anterior Left Lateral Ventricle = green r Patients Normal ControlsMakris et al., 2004 Neuron Common 8
    • Model of addictionAddictive agent Euphoria/ Positive Reinforcement activated reward pathways Drug Administration/ Neuroadaptations Drug-Seeking Behavior Withdrawal and Tolerance Failed impulse suppression Protracted hedonic dysregulation Drug Craving/ Negative Reinforcement Dysregulated reward pathways Drug-related cues Limbic activation Stress 9
    • AddictionAddiction is a disorder of brain reward centers that normally insure the survival of organisms and the speciesDrugs activate and dysregulate endogenous reward systems such that attention, motivation, behavior are directed away from survival goals and toward drug-related cues Dackis and O‟Brien, 2001Defined by loss of control over intense urges to take the drug despite adverse consequences Volkow and Fowler, Cereb Cortex 2000 10
    • Onset Substance use disorders typically have onset during adolescence and young adulthood and tend to have a chronic course without intervention - 90% of all adults with alcohol/drug dependence started using under the age of 18, half under the age of 15 (NSDUH, 2006)  75% of High School students have tried alcohol  Nearly 50% of seniors drink at least once a week  1 out of 4 seniors uses illicit drugs  1 out of 3 teens, age 14-17, have used an illegal drug more than once Brain development continues well into mid-20‟s  Sustained binge drinking may affect this process, may result in damage to frontal-cortical regions  Early intervention and recovery management offers hope for shortening the intensity and course of the illness 11
    • Age at Onset of DSM-IV DrugAbuse and Dependence Compton et al. Arch Gen Psychiatry/ Vol 64, May 2007; 45(11): 1294 - 1303 12
    • Who is Vulnerable? Adolescents 40-60% of vulnerability for addiction genetically influenced Addiction is more prevalent in people who have the following childhood psychiatric disorders:  Depression and Bipolar Disorder*  Anxiety  Schizophrenia  Post-Traumatic Stress Disorder  Attention Deficit Hyperactivity Disorder  Conduct Disorder** Denotes largest risk factor: Over half develop substance abuse N. Volkow, 2007, Director National Institutes on Drug Abuse Goldman, et al; ‘05 Nature Rev. Gen.; Hiroi, et al; ‘05 Mol Psychiatry 13
    • Substances of Abuse are Deleterious in Adolescent Brain Development Negative CNS effects of chronicPrefrontal structures alcohol use in teens: - Learning - Information recall, memory (verbal, nonverbal) - Vocabulary - Sleep (mood, attention) Striatum & HippocampusMedial Wall 14
    • Relationship between Mental Healthand Substance Use Disorders Complex, multifaceted Genetics/ neurobiological Affected by multiple systems of adolescent/young adult life  Family, Community/ School, Peers, Media Life stresses, academic and social issues Dynamics-self medication Changes with maturation, normal development Substance use can worsen the severity of pre-existing mental health conditions; untreated mental health issues exacerbate substance use 15
    • Clinical Imperative Substance Use Disorders are Highly Prevalent, Under-recognized and Under-treated Screening is fast and effective Even brief intervention can effect salutary change Early Intervention is optimal 16
    • What Can Be Done? Treatment works; extensive models are best suited to the nature of addiction Effective treatments exist:  Pharmacotherapy Rarely Prescribed  Cognitive-behavioral therapy  Motivational Interventions  Community Reinforcement Model  12-step facilitation  Family therapy 17
    • Innovative Models of Care Extensive models are best suited to the nature of addiction  “Aftercare” – Continuing Care – Treatment  Case monitoring  Recovery management Assertive Continuing Care Mutual Help Groups/Peer Support Program Evaluation  Science-based practice  Practice-based science  Intermediate Outcomes/Theory  Provides for systematic evaluation; identification of patient subgroups/non-responders 19
    • Treatment Challenges - Stigma Conceptualized as a disorder of „Free Will‟  “substance abuser” Perhaps even more than other mental illness, patients with substance use disorders feel strong sense of shame/embarrassment, and self-loathing Shame associated with substance use creates a barrier to accessing treatment and disclosure/open communication Substance use disorder is a chronic health condition similar to hypertension, diabetes and yet is not treated as such 20
    • Is Substance-RelatedTreatment Worth Its Cost? Addiction treatment is highly cost-effective Every $1 invested in addiction treatment programs yields a $4-7 saving in reduced drug-related crime, criminal justice costs, and theft alone. When health care savings are included, total exceeds costs by ratio of 12 to 1 Major savings to the individual and society also come from significant drops in interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents. Measuring and Improving Cost, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, NIH, NIDA 1999. 21