Addiction A Chronic Brain Disease Flora Sadri DO

Addiction: A Chronic Brain Disease Flora Sadri, DO, MPH, FAAFP Area Medical Director, Clean. Slate Centers Kentucky Academy of Family Physicians August 4, 2017

Flora Sadri, DO, MPH, FAAFP Area Medical Director, Clean. Slate Centers President, Massachusetts Academy of Family Physicians Chair, Commission on Government and Advocacy, American Academy of Family Physicians (AAFP) Vice Chair, Legislative Advocacy Committee, American Society of Addiction Medicine (ASAM)

ASAM’s Definition of Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. O reward and/or relief by substance use and other behaviors.

Addiction: Changes in the Brain A chronic, relapsing brain disease Drugs change brain structure and function Brain changes can be long-lasting

Addiction is a chronic brain disease Federal government: (Surgeon General, NIDA, SAMHSA, NIAAA) Physician Organizations: (AMA, ASAM, etc) NOTE: not everyone with a substance use disorder has the disease of addiction not everyone who appears drug seeking/doctor shopping has the disease of addiction not everyone who uses illicit drugs has the disease of addiction, or a substance use disorder – how do you kow it when you see it?

American Society of Addiction Medicine (ASAM) Addiction Definition, April 2011 • Affects neurotransmission such that addictive behaviors replace healthy self-care related behaviors • Genetics account for 50% of addiction development • Significant self-deception Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry • Disruption of healthy supports and problems in interpersonal relationships • History of trauma or stressors that overwhelm an individual’s coping abilities • The presence of co-occurring psychiatric illness • Distortion in meaning, purpose and values that guide attitudes, thinking and behavior • The effects to the brain allow external cues to trigger craving and drug use • Persistent risk of and/or recurrence of relapse • Impaired executive function so that perception, learning, impulse control. , compulsivity and judgment are impaired. American Society of Addiction Medicine (ASAM) Addiction Definition, April 2011

SUBSTANCE USE DISORDER (SUD) Symptoms are in four major categories » Impaired control » Social impairment » Risky use » Tolerance and withdrawal

4 C’s of Addiction Compulsive Use Continued Use Despite Harm Loss of Control Cravings

Risk factors for developing addiction We can impact 2 out of 3 And lack of exposure to the substance means the brain will not develop addiction to the substance

Genetics Account for 50% of Risk of Addiction

Adverse childhood experiences Adverse Childhood Experiences Emotional Neglect Abuse Emotional Household Dysfunction neglect Abuse Household dysfunction

Risk factors for developing addiction We can impact 2 out of 3: • Early exposure • • Traumatic childhood due to abuse/neglect/missing parenting • (community based resiliency training) (treating adults with addiction helps prevent their kids from being addicted) And Iatrogenic Addiction can be prevented: Lack of any brain exposure prevents the brain's addiction to the substance The minority of overdose deaths are under age 25. This is an epidemic impacting middle aged and older adults

Act First, Think Later This is Normal Development More Risky Impulsive Behavior Less than Optimal Planning Preference for Physical Activity and Sensation Seeking Emotions Felt Very Intensely Less Consideration of Negative Consequences Strongly Influenced by Friends and Peers

Rate of Change Brain Development Source: Tapert & Schweinsburg, 2005

Dopamine Receptors

Synaptic Refinement

Myelination

Dopamine Pathways Serotonin Pathways Functions • • • Reward (motivation) Pleasure, euphoria Motor function (fine tuning) Compulsion Perseveration Mood Memory processing Sleep Cognition

Addiction is a Developmental Pediatric Disease Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003

How Heroin Works

Opioid Addiction: A Chronic Brain Disease Goals of treating chronic conditions: Decrease related morbidity and mortality; decrease total cost of care increase functioning / quality of life

Drug Dependence is a Chronic Medical Illness » Diabetes Type I – 60% Medical Adherence » HTN – Less than 40% Adherence » Asthma – Less than 40% Adherence » Drug Abuse – 40% - 60% Adherence

Addiction as a Chronic Disease Addiction Hypertension 25 -50% Genetic Mc. Lellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: Implications for 40 -60% Relapse 50 -70% Relapse treatment, insurance, and outcomes evaluation. JAMA. Initial choices: alcohol/drug Initial choices: food, activity 2000 oct; 284(13): I 168 -95. 30 -60% Genetic Potential permanent physiological changes Abstinence and medications do not reverse disease Lifestyle changes and medications do not reverse disease < 50% adhere to drug abstinence 1 year post-treatment < 40% adhere to medication, 30% adhere to lifestyle changes

FACT OR FICTION ADDICTION IS A CHOICE?

FACT OR FICTION ADDICTION IS A CHOICE FALSE ADDICTION IS A DISEASE

Chronic Relapsing Brain Disease » Treat the condition like DM, HTN, CAD, CVD » Long-term abstinence without MAT <5% » Key elements: empathy, compassion and knowledge – We are passionate about this work because it is the right thing to do for patients and their families – ASAM/ABAM continuing education and mentoring

FACT OR FICTION PEOPLE USE BECAUSE THEY JUST WANT TO GET HIGH?

FACT OR FICTION PEOPLE USE BECAUSE THEY JUST WANT TO GET HIGH FALSE

FACT OR FICTION TAKING SUBOXONE OR METHADONE IS JUST SUBSTITUTING ONE DRUG FOR ANOTHER? FALSE!

FACT OR FICTION FACT: Methadone or Suboxone are the primary treatments associated with decreased opioid addiction related mortality, morbidity, cost of care, and improved functioning.

RATIONALE FOR MEDICATIONS in ADDICTION TREATMENT (MAT) Consistent with understanding that Addiction is a Chronic Disease, Maintenance Treatment works! DECREASES WITHDRAWAL SYMPTOMS BLOCKS EUPHORIA FROM OPIATES REDUCES CRAVINGS DECREASES OPIATE USE Detoxification is not effective Inpatient care without ongoing medication leads to increased death risk Long-term abstinence without MAT <5%

FACT OR FICTION ADDICTS CAN JUST STOP USING IF THEY WANT TO? “JUST SAY NO”

FACT OR FICTION ADDICTS CAN JUST STOP USING IF THEY WANT TO “JUST SAY NO” IT’S NOT THAT EASY

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This is Addiction