Download Addiction as a Chronic Brain Disease

Addiction as a
Chronic Brain Disease
Ralph Dell’Aquila MD, C.C.F.P., M.R.O. ,
American Board of Addiction Medicine
Nurture North MAR Clinic
Northern Ontario Mental Wealth Centre
Northern Ontario School of Medicine
LHIN CDPM ,
Sudbury
Oct 12 ,2012
Declaration of Interests
Medical Advisory Group: Reckitt
Benckiser (speaker fees)
Scientific Advisor for several local
non-profit groups

ACNBA, P4L, NBRH
NOMWC Board Member
OUTLINE
1.
2.
3.
4.
5.
How the Brain Works
How Alcohol & Drugs can Hijack the Brain
Addiction as a chronic brain disease
How the Brain can Heal
Evolving Treatment Approaches
Emotional Regulation
Prefrontal cortex controls lower functions of
limbic system
• Motivation and emotion
• Assigns feeling to
incoming stimuli
• Emotional drives
• Stress responses
• Provides for
rewarding &
addictive properties
of drugs
Dopamine Pathways: Go/ No-Go
Neuronal Pruning
EXECUTIVE FUNCTIONS
Building blocks form in childhood
•
•
•
•
•
•
Forethought
•
Attention/Concentration
•
Verbal Ability
•
Abstract Reasoning
Problem Solving
•
Programming and
Planning Goal Oriented
Behavior
•
• Behavioral Inhibition
Learning from
Experience
Interpreting Social Cues
Using Socially Adaptive
Behavioral Responses
Avoiding Negative
Consequences or
Situations
Regulating Emotional
Responses
• Sensitivity to Penalties
Addiction is a Complex Disease
Biology/genes
Biology/
Environment
Interactions
Environment
EPIGENETICS
Genetic Contribution to Drug Abuse and Addiction…
….Overlapping with Environmental Influences
Why Do People Take Drugs in
The First Place?
To feel
good
To have novel:
feelings
sensations
experiences
AND
to share them
To feel
better
To lessen:
anxiety
worries
fears
depression
hopelessness
Continuum of Substance Use
Circuits Involved In Drug Abuse and Addiction
Brain changes resulting from prolonged use of drugs
may compromise mental and motor functions
Why does addiction happen?
Reward-seeking behaviours
have evolved as a means of
survival of species
Drugs HIJACK
Brain Reward Circuits
and Motivational Priorities
(dopamine system)
This is why addicts can’t just quit
This is why treatment is essential
Addiction is Like Other Diseases…




It is preventable
It is treatable
It changes biology
If untreated, it can last a lifetime
Decreased Brain Metabolism
in Drug Abuser
Decreased Heart Metabolism
in Heart Disease Patient
High
Low
Healthy Brain
Diseased Brain/
Cocaine Abuser
Healthy
Heart
Diseased Heart
DECREASED DOPAMINE TRANSPORTERS IN ADDICTION
Healthy Person
Active Addiction
14 months Rx
Source: J Neurosci 21:9414–9418, 2001.
Patients Who Relapse (%)
Relapse Rates Are Similar to
Other Chronic Diseases1,2
80
70
60
50%–70%
50%–70%
Hypertension
Asthma
40%–60%
30%–50%
50
40
30
20
10
0
Drug Addiction Type 1 Diabetes
1. McLellan AT et al. JAMA. 2000;284(13):1689-1695; 2. National Institute on Drug
Abuse. http://www.nida.nih.gov/scienceofaddiction/sciofaddiction.pdf. Accessed June
30, 2011.
18
Benefits of the Chronic Disease Model
Emphasises comprehensive, sustained treatment
to help retain patients, maintain adherence, and
focus on success
Minimises stigma associated with opioid
dependence
Promotes continuity of care
Underscores the importance of ongoing
monitoring
Reinforces the need for a multifaceted,
multidisciplinary treatment approach
Van den Brink W, Haasen C. Can J Psychiatry. 2006;51(10):635646.
19
Similarities to Other Chronic
Diseases1-3Diabetes, Asthma,
Characteristics
Drug Dependence
and Hypertension
Well studied


Chronic disorder
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
Predictable course

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Effective treatments

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Curable
NO
NO
Heritable

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Requires continued care

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Requires adherence to treatment
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Requires ongoing monitoring


Influenced by behaviour


Tends to worsen if untreated


1. McLellan AT et al. Addiction. 2005;100(4):447-458; 2. McLellan AT et al. JAMA. 2000;284(13):1689-1695;
3. McLellan AT. Addiction. 2002;97(3):249-252.
20
CHRONIC DISEASES:
Social or biological ?
diabetes,
asthma
CV disease,
skin disease,
mood disorders, schizophrenia
addiction
Only ADDICTION Has:
LANGUAGE, LABELS & STEREOTYPES of
SOCIAL JUDGEMENT……”the methadone patient”
What is Addiction ?
* chronic, neurobiological disease
* starts in adolescence
Complex interactions between
genetic & environmental factors
•ADDICTION IS NOT:
•A moral Failure or A character flaw
Addiction & Public Health
A disease with many consequences
MEDICAL
ECONOMIC
SOCIAL
VIOLENCE
CRIMINAL
JUSTICE
8 Principles of Effective Treatment
Addiction is a complex but treatable disease
No single treatment is appropriate for everyone.
Continuous Treatment needs to be readily
available
Effective treatment attends to multiple needs of
the individual
8 Principles of Effective Treatment
Behavioral therapies are the basis of drug
abuse treatment.
Combining medications with behavioural
therapies can increase effectiveness.
Many individuals also have other mental health
disorders.
Medically assisted detoxification is the first
stage of treatment and by itself does little to
change long–term drug abuse.
Retain patients
Minimise withdrawal
symptoms and
cravings
Provide medical, social
and psychological
treatment
Stabilize Health:
Biological,
Psychological,
Social, Financial,
Spiritual
Improve Functional
Status
Improve Socio-economic
Status (SES)
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Medication Assisted Recovery
Social
Health
Financial Health
Psychological Health
Biological Health
Spiritual Health
Current Treatment Models & Attitudes
Episodic Treatment
Provider Experience & Philosophy
Varying Program Philosophies
Lack of Scientific Evidence for Treatments
Inconsistent Quality
Fragmented Silos of Care
Emphasis on Residential Model
Evolving Treatment Models & Attitudes
Public Health Pillars approach
Team Approach: Circle of Care; Care Map
Integrated Case Management
Integrated Electronic Medical records
Medication Assisted Recovery
Contingency Management
Continuous Comprehensive Management
Culturally Competent Tailored Treatment
Appropriate Levels of Care (inpt vs outpatient)
Accessible Quality Care. Bottom Up Approach
Target & Measure Specific Outcomes
Bench to Bedside: Research + Clinical Evolution
Long-Term Treatment Is Associated
With Positive Outcomes
Patients (n=5577) receiving medication-assisted treatment with
either methadone or buprenorphine in the United Kingdom
Probability That Treatment Reduces Overall Mortality
Cornish R et al. BMJ. 2010;341:c5475.
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Prolonged Medication-Assisted
Treatment Sustains Improvement
4 Studies of Various Treatment Lengths
After 6 Months1
After 12 Months2
(buprenorphine-only; n=690)
(buprenorphine-only; n=40)
•
Heroin use decreased by 81%
•
Codeine use decreased by 83%
•
•
•
•
•
Benzodiazepine use decreased
by 48%
Cocaine use decreased by 74%
•
•
•
32% improvement in
occupational problems
90% improvement in
drug-related problems
90% improvement in
crime-related problems
After 18 Months3
After 2 to 5 Years4
(buprenorphine/naloxone; n=176)
(buprenorphine/naloxone; n=53)
Less likely to report using any
substance or heroin
More likely to be employed
Improved on several
psychosocial parameters
•
•
91% of urine samples were
opioid negative
96% of urine samples were
cocaine negative
1. Lavignasse P et al. Ann Med Interne (Paris). 2002:153(suppl 3):1S20-1S26; 2.
Kakko J et al. Lancet. 2003;361(9358):
662-668; 3. Parran TV et al. Drug Alcohol Depend. 2010:106(1):56-60; 4. Fiellin DA
et al. Am J Addict. 2008;17(2):116-120.
Treatment Benefits Outweigh Costs
Hart WA.
http://www.health.gov.on.ca/english/public/pub/ministry_reports/methadone_taskforce/methad
one_taskforce.pdf. Accessed September 9, 2011.
33
POA-ORT Longitudinal
Observational Study (in prep)
Patients Remaining in Active Treatment
% of Patients
100%
80%
60%
40%
20%
0%
Year 1
Year 2
Year 3
Annual Retention Rates
Year 4
POA-ORT DESCRIPTIVE STUDY:
COMORBIDITY
Comorbidity at Intake
60%
% of Patients
50%
40%
30%
20%
10%
0%
Concurrent
Psychiatric
Disorder
Sleep Disorder
Mixed Pain
Disorder
History of IV
Drug Use
Hep C Positive
POA-ORT Longitudinal
Observational Study (in prep)
Treatment Outcome
70%
% of Patients
60%
50%
40%
30%
20%
10%
0%
Year 1
Year 2
Success
Year 3
Intermediate
Year 4
Fail
POA-ORT Longitudinal
Observational Study (in prep)
Positive Urine Drug Screens
40%
35%
% of Patients
30%
25%
20%
15%
10%
5%
0%
Intake
Year 1
Opiates
Year 2
Cocaine
Year 3
Benzodiazepines
Year 4
Deliverable Outcomes in MHA
Outcome
Domains
ORT
RTS 1
RTS 2
MHC
CCC
ACTT
Efficacy
80%
??
??
??
??
??
Biological
UDS
improved
n/a
n/a
n/a
n/a
n/a
Neurocog
pending
Psychologic
pending
QoL, GAF
improved
SES
improved
Performance Measures in MHA
Domains
MAR
Clinic
RTS 1
RTS 2
MHC
CCC
ACTT
LOS
Continous
21d
90d
Cont +
series
conttinous
continous
Case #
340
30
> 1yr
340
n/a
70
Wait Time < 30d
approx 3
mos
16 mos
3mos?
>3mos?
n/a
Retention
80%
55% ?
n/a
n/a
n/a
n/a
Monthly
case cost
$180
$6,500
Managed $ Block $
$5,500
Block $
$650
Block $
N/A
Block $
$1,200
Block $
QALY
TBD
TBD
TBD
TBD
TBD
TBD
CCM ?
LEAN ?
MHA +
More ICM
No Med
No Med No
Addxn
No Med
MH
No
addxn
Closing SUMMARY
1.
2.
3.
4.
5.
6.
7.
8.
How the Brain Works
How Alcohol & Drugs can Hijack the Brain
Addiction as a chronic brain disease
How the Brain can Heal
Evolving Treatment Approaches
Early Treatment of MHA as chronic brain
disorder improves outcomes
Modern treatment produces cost-effective
quantifiable results
Future collaborations & Pilot Studies
Thank You !
Questions ?
Nurture North MAR Clinic
Northern Ontario Mental Wealth Centre
239 Main St. East
North Bay ON
Tel 705-478-7197
Fax 705-478-0861
[email protected]
References
Beddington, J. et. al. (2008) The mental wealth of nations. NATURE,
Vol 455: 1057-1060.
Gnam, W. et al, (2006) The Economic Costs of Mental Disorders
and Alcohol, Tobacco, and Illicit Drug Abuse in Ontario,
2000: A cost of Illness Study (CAMH)
Why Can't They Just Stop? Hoffman and Froemke (HBO)
Minden, K. Yamada.S.Waiting for What? An inquiry into the
fundamental questions of how to fix adolescent mental
health care. Healthcare Quarterly Vol.14 Special Issue
October 2011
NIDA 2009. Principles of Drug Addiction Treatment: A Research Based
Guide (2nd ed.) http://www.nida.nih.gov/podat/PODATIndex.html