Orientation to addiction medicine and recovery

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Addiction Medicine: Orientation to the Science of Addiction

or

An experienced addictionist reflects on applying science to service

October 23, 2010

4th Annual Addiction & Compulsive Behaviors SymposiumPaducah, KY

Al J. Mooney MDMedical Director, The Healing Place of Wake CountyChairman, Willingway FoundationAssociate Clinical Professor of Family Medicine, UNC Chapel Hill

Discussion point #1

Solving America’s #1health problem

Alcoholism and drug dependency conditions are major contributors to morbidity and mortality in mental health and physical health environments

Discussion point #2

“If a tree falls in the woods and nobody is there, does it make a noise?”

Knowledge of recent addiction science and neuroscience strengthens our understanding of addictive illness and recovery

Discussion point #3

“That’s an ugly mole. Let’s take it off so you don’t get melanoma”

A person who has consumed 5 drinks or more (4 for women) on any day in the past year is a “risky drinker”

Discussion point #4

“Walk a mile in my shoes”

Peer and mutual support (AA, NA, 12 step work, and mutual support) are promising to be effective bridges to life-long addiction recovery

Discussion point #5

“S*** happens”

Understanding that life-long recovery exists in three phases (or zones) assists an individual establish healthy sobriety and negotiate good and bad times throughout their recovering life

Putting it all together

There is a problem

We can identify the problem

There is a free solution

We can connect the free solution with the problem

Where science meets the sickness

What evidence is there that the alcohol and drug problem is the number one

health problem in America?

Disease facts – The problem Fatal illness

100,000 deaths annually YPLL = Cancer + Heart Disease >80% unanticipated deaths in community mental

health Number 1 Health problem

$466 billion annual cost of NOT treating No claims data to use for policy formulation

7% U.S. population afflicted ¼ of hospital admissions Family morbidity 43% (76,000,000) 100% increase in healthcare costs Primary cause of preventable birth defects Treatment yield of $7 for $1 expense $39 Yield for each $1 spent in medical settings Prevention reduces risk by 75%

How to be “blinded by the evidence”

Scientific methods are being used in ways that corrupt measurement of meaningful outcomes

Adjust length of study to misrepresent outcome Measure effects that justify use of medication Avoid measurement of side effects Emphasize statistical endpoints not relevant to clinical

efficacy Pay researchers to publish positive outcomes Don’t report negative results Publish research ghostwritten by marketing staff under

physician bylines Avoid comparison with alternatives known to be effective

11

Suicide (1950-2005)

Sources: Centers for Disease Control and Prevention, National Center for Health Statistics. From Health, United States, 2005

Suicide by age (1990-2005)

Infection Death Rates

Seroquel sales 2009 vs. Astra-Zeneca settlement

Seroquel Sales $4.9 Billion

Lawsuit Settlement - $520 Million

Settlements for illegal or unethical drug marketing

practices

Astra Zeneca $520,000,000 http://www.astrazeneca-us.com/about-astrazeneca-us/newsroom/8936389?itemId=8936389

Pfizer $2,300,000,000 http://www.ama-assn.org/amednews/2009/09/14/prl20914.htm

Purdue Pharma $634,500,000 http://www.nytimes.com/2007/05/11/business/11drug.html?_r=1&scp=1&sq=Purdue%20Pharma

%E2%80%99s%20May%2011%20plea%20agreement%20&st=cse

Lilly $1.400,000,000

http://www.bmj.com/content/338/7688/News.full.pdf

http://www.taf.org/top20.htm

Disease facts – The problem Fatal illness

100,000 deaths annually YPLL = Cancer + Heart Disease >80% unanticipated deaths in community mental

health Number 1 Health problem

$466 billion annual cost of NOT treating No claims data to use for policy formulation

7% U.S. population afflicted ¼ of hospital admissions Family morbidity 43% (76,000,000) 100% increase in healthcare costs Primary cause of preventable birth defects Treatment yield of $7 for $1 expense $39 Yield for each $1 spent in medical settings Prevention reduces risk by 75%

Drug types

Alter a diseaseAlter our perception of reality

Example: Benadryl

Help allergy symptoms

Example: Benadryl

Help allergy symptomsSedation or antianxiety = relapse risk

Example: Morphine

Assist heart pumpingEuphoria or high = relapse risk

Alcohol effect on brain< 0.05% Prefrontal Cortex

disinhibition

> 0.05% Amgdyla emotional

>0.20% RAS hypnosis

>0.30% Medulla - Respiratory depression and death

>0.10% Cerebellum –ataxia

Drugs of abuse

Stimulants

Narcotics

Sedatives

Other

Drugs of abuse

Alcohol

Heroin

Crack

PaxilMorphine

BenadrylMarijuana

PCP

LSD

Crystal Meth

Special K

“T”

Valium

AtivanXanax

Codiene

Butalbital

Ambien

Ultram

Adderal

Ritalin

Chloral Hydrate

Peyote

GlueBuprenorphineMethadone

Dextromethoraphan

Restoril

SomaMethaqualoneKlonopin

Zoloft

Prozac

Ice

Tolerance and dependenceC

NS

Act

ivity

Time

Tolerance and dependenceC

NS

Act

ivity

Time

Tolerance and dependenceC

NS

Act

ivity

Time

Tolerance and dependence vs. addiction

CN

S A

ctiv

ity

Time

Addictive cycle

1. Physical Allergy

2. Mental Obsession

Natural rewards survival urges (nutrients)

Air Food Water Sex

Intimacy (connectedness)

Addiction Brain

Addiction Cascade

Drink

Drunk

Abstain

“Trouble”

Switch Chemicalor beverage

Urge to use

Use again

Addiction Cascade

Drink

Drunk

Abstain

“Trouble”

Switch Chemicalor beverage

Urge to use

Use again

Abandon values Self-deception(Denial)

Addiction is progressive

Symptoms

Onset

Disability

Diagnosable

Death

Sev

erity

Time

Addiction is progressive

Symptoms

Onset

Disability

Diagnosable

Death

Sev

erity

Time

Addiction is progressive

Symptoms

Onset

Disability

Diagnosable

Death

Sev

erity

Time

Addiction and health nationally: Brain science

Neuroplasticity Survival function of brain Brain mapping Executive function Abstinence

Evidence based medicine

Science behavior change MH/PC Integration SBIRT Peer methodology

Identifying the problemDrinking in America

Motivational Readiness

Precontemplation

Contemplation

Preparation

Action

Maintenance

Clinician’s Guide – Helping People Who

Drink Too Much

Do you sometimes drink alcohol?

Single question screening

Ask: “In the past year how many times have you had

5 drinks or more in a 24 hour period of time?” (4 for women)

If greater than 0:The “risky drinker” needs intervention/treatment

Call peer recovery volunteer

46

Peer specialty development

Understand the mortality of public mental health Solicit capacity for Angel calls Identify those at risk or with a desire to stop

MH/PC integration (SBIRT) Screening, triage, referral (STR) points

Introduce the culture of recovery Leadership development Empowers “tracer” methodology for quality

SBIRT methodology

Step 1: Ask about alcohol use Step 2: Assess for alcohol use disorders

At-risk drinking Alcohol use disorders

Step 3: Advise and assist Step 4: Followup and continue support

History of “Angel Calls”

1935 – Mutual support recovery and 12th step work

2001 – Department of Surgery U of L collaborates with The Healing Place

2004 – Rick Blondell investigates with inpatient clinical trial methodology

2006 – North Carolina replication of a similar community model in a public mental health system

2008 – Other replications in NC and acute care

Promote success in recovery by engaging and linking its phases:

–Next, do something worthwhile with it

–Finally, live as long as you can

The Recovery Book

–First, save your life

Recovery phases or zones

Phase I. Salvage life

Phase II. Make life worthwhile

Phase III. Prolong life

Safety Zone

Work Zone

Comfort Zone

Zones in the recovery timeline

Initial recovery Reconstruction

Terminal illnessYears

Summary

Most recover with proper motivation and treatment

Recovery happens in phases Application of the principle of “Zones” will

improve length and quality of recovery

THE RECOVERY BOOK

Al J. Mooney MD

509 Midenhall Way

Cary, NC 27513

Mobile: 919 238 9349

Email: amooney@aol.com