Introduction to AddictionHuman BehaviorLisa J. Merlo, Ph.D. McKnight Brain Institute Department of Psychiatry Division of Addiction Medicine
Objectives• Describe DSM-IV criteria for Substance Use Disorders (SUDs)• Review epidemiology of SUDs• Explain neurobiology of addiction and “disease model”• Introduce Screening, Brief Intervention, & Referral to Treatment (SBIRT) for addiction
What is Addiction? “Addiction” is a non-specific term that is frequently used to refer to a variety of substance-related disorders
Substance AbuseMaladaptive pattern of substance use, characterizedby 1 (or more) of following symptoms in a 12-monthperiod: 1. Recurrent substance use resulting in failure to fulfill major role obligations 2. Recurrent substance use in situations in which it is physically hazardous 3. Recurrent substance-related legal problems 4. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance** The symptoms have never met the criteria for Substance Dependence for this class of substance
Substance DependenceMaladaptive pattern of substance use, characterizedby 3 (or more) of following symptoms in a 12-monthperiod: 1. Tolerance (need for more or diminished effect) 2. Withdrawal (characteristic syndrome or avoidance of symptoms) 3. Substance taken in larger amounts or over a longer period than intended 4. Persistent desire or unsuccessful efforts to cut down or control substance use 5. Great deal of time spent obtaining, using, or recovering from effects of the substance 6. Important social, occupational, or recreational activities are given up or reduced because of substance use 7. Substance use continued despite knowledge of having a persistent or recurrent physical or psychological problem that was likely caused or exacerbated by the substance
ALL physicians need to knowabout addiction because:• 1 out of 7 individuals will have a serious substance use problem (13.5% lifetime prevalence)• 1 out of 3 Americans are directly affected by addiction• Up to 50% of admissions to the ER are substance-related• Addiction is a common problem among physicians and other health care providers
Alcohol Guidelines• Moderate drinking = • No more than 1 drink per day for women • No more than 2 drinks per day for men• Binge drinking = • > 4 drinks for women • > 5 drinks for men
Perceived Risk vs. Actual Use• Decades of research have demonstrated that drug use is inversely related to perceived risk of taking the drug• As population-wide perceptions of the risk of drugs decrease, use of those drugs increases
Drug Trends: 2007• Declining • Marijuana • Amphetamines • Overall use of any illicit drugs• Holding Steady • Cocaine, LSD, Heroin• Increasing • Ecstasy • Prescription Drugs (decade trend)
“Legal” Drug AbusePercentage of U.S. Teens (Grades 7 to 12) Reporting Ever Trying Drugs, 2008 (N=6,518) Marijuana 33% Inhalants 19% Prescription Drugs 19% O TC Cough Medicine 10% Crack/Cocaine 9% Ecstasy 8% LSD 7% Meth 6% Ketamine 5% Heroin 5% GHB 4% 0% 5% 10% 15% 20% 25% 30% 35%
Trends in Florida Number of Drug-Caused Deaths Per 100,000 Residents in Florida 4 3 Heroin-Caused Deaths 2 Methadone-Caused 1 Deaths 0 2001 2002 2003 2004 2005Merlo LJ, Goldberger BA, Gold MS. Patterns of heroin- and methadone-related deaths inthe state of Florida. Society for Neuroscience Annual Conference, 2007. San Diego, CA.
Past Month Non-Medical Use of Prescription Drugs among Persons 12+ Percent Using in Past Month 3 2002 2003 2004 2.0 2.1 2005 2006 + 1.9 2 1.9 1.8+ 2 1 0.8 0.8 0.7 0.7 0.7 0.5 0.5 0.5 0.5 1 0.4 0.2 0.2 0.1 0.1 0.1 0 Pain Relievers Stimulants Sedatives Tranquilizers+ Difference between this estimate and the 2006 estimate is statistically significant at the .05 level.
Addiction is a Brain Disease• Not lack of will power or poor judgment• Impaired control is caused by brain chemistry malfunction• Drug use produces brain damage!
Why Does Addiction Occur? From: www.nida.nih.gov•Some drugs of abuse can release 2 to 10 times the amount of dopamine as natural rewards•In some cases, this occurs almost immediately (as when drugs are smoked or injected), andthe effects can last much longer than those produced by natural rewards•This creates a much stronger effect on the brains pleasure circuit than those producednaturally (e.g., food, sex)•The effect of such a powerful reward strongly motivates people to take drugs again and again
Imaging StudiesPatients who abuse substances show:• Structural abnormalities (MRI/MRS): • frontal cortex, prefrontal cortex, basal ganglia, and amygdala• Functional abnormalities (fMRI, PET, SPECT): • caudate nucleus, cingulate, and prefrontal cortex become activated during a drug “rush” • nucleus accumbens becomes activated during periods of craving • striatal dopamine spike associated with the pleasurable drug- related “high”
Effects of Chronic Drug Use • With repeated use, drugs cause profound changes in neurons and brain circuitry • These changes are associated with “tolerance” • Decreased dopamine transporters result in depression-like symptoms • Drugs are needed to “return to baseline”
The SPECT images (top-down surface view)depicting a normal brain vs. a brain affected bychronic marijuana use Defects of this type have been associated with attention problems, disorganization, procrastination and lack of motivation.
DevelopmentalNeurobiologyEarly brain exposure to drugs of abuse: • in utero • through secondhand exposure • and/or through early experimentationsensitizes the brain, making abuse and dependencemore likely• In an animal model, rats who were exposed to THC during adolescence show higher levels of opioid self-administration during adulthood than rats who were not exposed
Addiction: Age of Onset• Some experimentation during adolescence is developmentally “normative” behavior• However, addiction is now being referred to as a “disease of pediatric origin”
Genetics• Twins • Identical 55%; Fraternal 28%• Adoption studies • genetics > environment• Tendency to become alcoholic is inherited • Alcoholic parent - 3 to 4 times higher • Adult children of alcoholics have abnormal brain cortisol reactions to stress• Drugs induce changes in genes
Clinical Application:Intervening With Patients
SBIRT• Screening• Brief Intervention• Referral to Treatment
SCREENING1. ASK your patients about their substance use: • How many alcoholic drinks do you have in a week? (not: “Do you drink alcohol?”) • What sorts of drugs do you use? • Tell me about your tobacco use and/or secondhand exposure.
SCREENING2. FOLLOW-UP on any positive responses: • CAGE questionnaire, Alcohol Use Disorders Identification Test (AUDIT), or Michigan Alcohol Screening Test (MAST) for alcohol • Drug Abuse Screening Test (DAST) or more intense interviewing for drugs • Fagerstrom Nicotine Dependence Test for tobacco
SCREENING3. Consider utilizing point-of-care testing: • Breath-alyzer, saliva, or urine testing for alcohol • Urine (or hair) testing for drugs • Urine, saliva, or breath testing for tobacco (nicotine)
BRIEF INTERVENTION• FRAMES Method: • offer Feedback • emphasize personal Responsibility • give Advice • provide a Menu of options • use Empathy • support Self-efficacy
REFERRAL TO TREATMENT1. Provide information on AA/NA Meetings2. Offer referral to outpatient addiction treatment clinic3. Suggest inpatient detoxification and/or long-term residential treatment
Florida Recovery Center• http://shands.org/hospitals/vista/professionals/default.aspFor Healthcare ProfessionalsShands.org seeks to provide tools and information to healthcare professionals to make iteasy to refer and transfer patients, answer medication questions, and provide tips forrunning a better business.ReferralsFor Professionals Homepage - Shands system-wide informationInformationTo learn more about Shands Vista, please call 352.265.5497.
Remember:• Addiction is a TREATABLE brain disease• Physicians must intervene to treat the addiction, not just the physiological symptoms that may result from chronic substance use