introduction to addiction

1. Introduction to Addiction Human Behavior Lisa J. Merlo, Ph.D.

3. What is Addiction? “Addiction” is a non-specific term that is frequently used to refer to a variety of substance-related disorders

4. Addiction is a brain disease

5. Addiction Addiction = “Substance Dependence” 3 Cs: Compulsive use Inability to Control use Continued use despite Consequences Addiction is not just physiological dependence

6. Substance-Related Disorders (DSM-IV, 2000) Substance Abuse Substance Dependence Substance Intoxication Substance Withdrawal Substance-Induced Mental Disorders Delirium, Persisting Dementia, Persisting Amnestic Disorder, Psychotic Disorder, Mood Disorder, Sexual Dysfunction, Sleep Disorder, Hallucinogen Persisting Perception Disorder Substance Use Disorder, Not Otherwise Specified

7. Substance Abuse Maladaptive pattern of substance use, characterized by 1 (or more) of following symptoms in a 12-month period: Recurrent substance use resulting in failure to fulfill major role obligations Recurrent substance use in situations in which it is physically hazardous Recurrent substance-related legal problems 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

8. Substance Dependence Maladaptive pattern of substance use, characterized by 3 (or more) of following symptoms in a 12-month period: Tolerance (need for more or diminished effect) Withdrawal (characteristic syndrome or avoidance of symptoms) Substance taken in larger amounts or over a longer period than intended Persistent desire or unsuccessful efforts to cut down or control substance use Great deal of time spent obtaining, using, or recovering from effects of the substance Important social, occupational, or recreational activities are given up or reduced because of substance use Substance use continued despite knowledge of having a persistent or recurrent physical or psychological problem that was likely caused or exacerbated by the substance

9. Substances of Abuse Alcohol (beer, wine, hard liquor) Amphetamine (methamphetamine, Adderall, diet pills) Caffeine (coffee, soda, tea, energy drinks) Cannabis (marijuana, pot, hashish) Cocaine (crack, coke, freebase) Hallucinogens (LSD, MDMA/Ecstasy, mescaline) Inhalants (gasoline, paint thinner, glue) Nicotine (tobacco) Opioids (heroin, methadone, Vicodin, Oxycontin, Percoset) Phencyclidine (PCP, ketamine) Sedative/Hypnotic/Anxiolytic (Valium, Xanax, sleeping pills) Other/Unknown (e.g., nitrous oxide) “Polysubstance”

10. Test Your Knowledge 1: How many chemicals are found in marijuana? 2 8 60 175 400

11. Test Your Knowledge 2: How long does the high from a hit of crack cocaine typically last? 1 minute 5 minutes 20 minutes 45 minutes 90 minutes

12. Test Your Knowledge 3: Which of the following poses the highest immediate risk? Inhalants Marijuana Tobacco LSD Crack

13. Epidemiology of Substance Abuse

14. ALL physicians need to know about 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

15. 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

17. Prevalence of Drug Use

18. 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

19. Drug Trends: 2007 Declining Marijuana Amphetamines Overall use of any illicit drugs Holding Steady Cocaine, LSD, Heroin Increasing Ecstasy Prescription Drugs (decade trend)

20. Public Health Response

21. “Legal” Drug Abuse

22. Trends in Florida

23. Past Month Non-Medical Use of Prescription Drugs among Persons 12+

24. Neurobiology of Addiction

25. 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!

26. Why Does Addiction Occur?

27. Imaging Studies Patients 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”

28. Effects of Chronic Drug Use

29. The SPECT images (top-down surface view) depicting a normal brain vs. a brain affected by chronic marijuana use

30. Developmental Neurobiology Early brain exposure to drugs of abuse: in utero through secondhand exposure and/or through early experimentation sensitizes the brain, making abuse and dependence more 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

31. 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”

32. 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

33. Clinical Application: Intervening With Patients

34. SBIRT Screening Brief Intervention Referral to Treatment

35. SCREENING 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.

36. SCREENING 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

37. SCREENING 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)

38. BRIEF INTERVENTION FRAMES Method: offer Feedback emphasize personal Responsibility give Advice provide a Menu of options use Empathy support Self-efficacy

39. REFERRAL TO TREATMENT Provide information on AA/NA Meetings Offer referral to outpatient addiction treatment clinic Suggest inpatient detoxification and/or long-term residential treatment

40. Florida Recovery Center http://shands.org/hospitals/vista/professionals/default.asp

41. 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

42. Thank You. Any questions? lmerlo@ufl.edu