Neurobiology of Addiction - ACMT · The Neurobiology of Addiction 2. Psychosocial Treatments 3....
Transcript of Neurobiology of Addiction - ACMT · The Neurobiology of Addiction 2. Psychosocial Treatments 3....
1
Petros Levounis, MD, MA Chair, Department of Psychiatry
Rutgers New Jersey Medical School
ADDICTION MEDICINE ACADEMY Clearwater Beach, Florida
March 26, 2015
Bench to Bedside: From the Science to the Practice of
Addiction Medicine
2
1. The Neurobiology of Addiction 2. Psychosocial Treatments 3. Pharmacological Treatments 4. Conclusions
Outline
2
1 Neurobiology of Addiction
3
2
4
~ 2000
The Fundamental Model
Biological
Psychological
Social
Use Brain Switch
Addiction
5
Olsen and Levounis, Sober Siblings, 2008.
6
2015
3
7
1. Continuum of Illness
2. Motivational Circuitry
3. Antireward Pathways
7
Three Novel Areas
GAME 1 ?
A. A sure gain of $250.
B. 25% chance to gain $1,000, 75% chance to gain nothing.
Adapted from: Tversky and Kahneman, Science, 1981.
Reward Systems
8
GAME 1 ?
A. A sure gain of $250. 84%
B. 25% chance to gain $1,000, 16% 75% chance to gain nothing.
Reward Systems
Adapted from: Tversky and Kahneman, Science, 1981.
9
4
GAME 2 ?
A. A sure loss of $750.
B. 25% chance to lose nothing, 75% chance to lose $1,000.
Antireward Systems
Adapted from: Tversky and Kahneman, Science, 1981.
10
GAME 2 ?
A. A sure loss of $750. 13%
B. 25% chance to lose nothing, 87% 75% chance to lose $1,000.
Adapted from: Tversky and Kahneman, Science, 1981.
Antireward Systems
11
GAME 1
25% + 750 25% - 250 25% - 250 25% - 250
GAME 2
25% + 750 25% - 250 25% - 250 25% - 250
MATHEMATICS
12
5
§ People avoid risks to ensure gains (even small gains).
§ People take risks (even big risks) to avoid definite losses.
§ Psychology trumps probability.
HUMAN NATURE
13
2 Psychosocial Treatments
14
15 15
1. Psychoanalysis works for all treatable mental illness.
2. Psychoanalysis does not work for addiction.
3. Therefore, addiction cannot be treated.
1st Wave: Psychoanalysis
15
6
16 16
The prototype, Synanon, was founded in California in 1958 to address heroin addiction.
The goal was to: Ø break down defenses, Ø bust through denial, and Ø reshape the addict’s personality.
2nd Wave: Boot Camps
16
17
The Frying Pan
17
Volkow et al, J Neuroscience, 2001
18 18
1. Mutual Help Groups (12-step)
2. Cognitive Behavioral Therapy
3. Family Therapy
4. Primary Care Services
5. Mental Health Services
6. Aftercare
3rd: The Kitchen Sink Approach
18
Nunes, Selzer, Levounis, Davies, Substance Dependence and Co-Occurring Psychiatric Disorders, 2010.
7
Mutual Help
19
20 20
Attitudes and Perceptions
20
PATIENTS
1. Inner peace 2. God 3. Medical Services 4. AA 5. Housing 6. Spirituality 7. Outpatient Tx 8. Community 9. Gov’t Services 10. Trusting People 11. Job
What Medicine Thinks
Patients Think 1. Housing 2. Outpatient Tx 3. Medical Services 4. Job 5. Trusting People 6. AA 7. Inner Peace 8. Community 9. Gov’t Services 10. Spirituality 11. God
MEDICAL STAFF
1. Housing 2. Gov’t Services 3. Medical Services 4. Outpatient Tx 5. Job 6. Community 7. Trusting People 8. Inner peace 9. God 10. Spirituality 11. AA
Goldfarb, Am J Drug Alcohol Abuse, 1996.
21 21 Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010. Graphic by Lukas Hassel.
4th: Motivational Interviewing (MI)
8
“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lie our growth and our freedom.”
Viktor E. Frankl
5th: Mentalization
Frankl V, Man’s Search for Meaning, 1959.
22
23
24
11.4
17.7
24.2 25
9.612.213.2
18.5
5.6
15.7
0
10
20
30
40
Only same-sex Mostly same-sex Equally both sexes Mostly other sex Only other sex
Women Men
% re
port
ing
any
subs
tanc
e us
e di
sord
ers
* ***
* Ref
*p<0.05, ***p<.001 based on logistic regression analysis adjusted for race, age, educational level, personal income, employment status, relationship status, health insurance status, geographic location, MSA, age at alcohol onset, and family history of AOD problems. Reference group was “heterosexual” group.
***
And Back to Psychodynamics…
Courtesy of Sean McCabe, PhD.
9
3 Pharmacological
Treatments 25
Porter and Jick, N Engl J Med, January 10, 1980.
26
The Prescription Opioids Epidemic: The Root of the Disaster
27
Chronic Non-Cancer Pain
10
Admissions: 1999 Primary non-heroin opioid admission rates (per 100,000)
28
Admissions: 2001 Primary non-heroin opioid admission rates (per 100,000)
29
Admissions: 2003 Primary non-heroin opioid admission rates (per 100,000)
30
11
Admissions: 2005 Primary non-heroin opioid admission rates (per 100,000)
31
Admissions: 2007 Primary non-heroin opioid admission rates (per 100,000)
32
Admissions: 2009 Primary non-heroin opioid admission rates (per 100,000)
33
12
0
1
2
3
4
5
6
7
8
9
10
'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06
Dea
th ra
te p
er 1
00,0
00
Heroin Cocaine
Unintentional Drug Poisoning Deaths United States: 1970 – 2007
Year
National Vital Statistics System, http://wonder.cdc.gov. 34
35
Alcorn, The Lancet, June 5, 2014.
Unintentional Drug Poisoning Deaths United States: 1999 – 2011
36 36
Ø Agonists: Methadone Nicotine Replacement
Ø Partial Agonists: Buprenorphine Varenicline
Ø Antagonists: Naltrexone
Addiction Strategies
36
Levounis and Herron, The Addiction Casebook, 2014.
13
37
-10 -9 -8 -7 -6 -5 -4 0
10
20
30
40
50
60
70
80
90
100
% Efficacy
Log Dose of Opioid
Full Agonist (Methadone)
Partial Agonist (Buprenorphine)
Antagonist (Naloxone)
The Ceiling Effect
37
Adapted from: Renner and Levounis, Office-Based Buprenorphine Treatment of Opioid Dependence, 2011.
4 Conclusions
38
1. Addiction hijacks the pleasure/reward and anti-reward pathways of the brain, as well as the person’s internal motivation.
2. Cognitive Behavior Therapy, mutual help groups, and Motivational Interviewing revolutionized addiction treatment.
3. In 2015, buprenorphine is the first line treatment of opioid use disorder.
39
14
Thank you
NJMS.Rutgers.edu/Psychiatry
40