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S. Alex Stalcup, M.D.

S. Alex Stalcup, M.D. New Leaf Treatment Center 251 Lafayette Circle, Suite 150 Lafayette, CA 94549 Tel: 925-284-5200 Fax: 925-284-5204 alex@nltc.com www.nltc.com. Addiction is a Pediatric Disease. 80% of addicts have risk factors known in childhood Family history of addiction

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S. Alex Stalcup, M.D.

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  1. S. Alex Stalcup, M.D. New Leaf Treatment Center 251 Lafayette Circle, Suite 150 Lafayette, CA 94549 Tel: 925-284-5200 Fax: 925-284-5204 alex@nltc.com www.nltc.com

  2. Addiction is a Pediatric Disease • 80% of addicts have risk factors known in childhood Family history of addiction ADHD (attention deficit hyperactivity disorder) Mood disorder (depression, anxiety, trauma) School failure • 80% of adult drinkers try alcohol before age 18. • Of children who begin drinking before age 14, 47% will become alcoholics. • Average age of initiation to marijuana use is age 15.

  3. What is a Drug? A drug is a pleasureproducing chemical. Drugs activate or imitate chemical pathways in the brain associated with feelings of well-being,pleasure and euphoria.

  4. Neuroadaptation, Tolerance, and Withdrawal Neuroadaptation is the brain’s response to over stimulation from drugs. Drug-specific circuits cause a mixture of sedation and stimulation or intoxication. Tolerance is the process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure neurotransmitters. In direct response to overstimulation, the brain regions decrease in sensitivity and become unresponsive (deaf) to normal levels of stimulation. In addition to pleasure circuits each drug type affects other specific circuits. Other brain pathways overstimulated by drugs also neuroadapt and become under active, directly leading to anxiety, depression, and loss of energy. Once neuroadaptation develops (tolerance), there will always be withdrawal symptoms that are the mirror image of the drug effects. Cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless, and lacking energy Under unstimulated conditions (without drugs) there is profound interference with the ability to experience normal pleasure. When sober, the user feels anhedonia, anxiety, anger, frustration and craving. The pleasure system remains impaired for months to years, interfering with sobriety, learning, and impulse inhibition.

  5. Definition of Addiction • Compulsion: loss of control The user can’t not do it s/he is compelled to use. Compulsion is not rational and is not planned. • Continued use despite adverse consequences An addict is a person who uses even though s/he knows it is causing problems. Addiction is staged based on adverse consequences. • Craving: daily symptom of the disease The user experiences intense psychological preoccupation with getting and using the drug. Craving is dysphoric, agitating and it feels very bad. • Denial/hypofrontality: distortion of cognition caused by craving Under the pressure of intense craving, the user is temporarily blinded to the risks and consequences of using.

  6. Abuse versus Addiction Substance Abuse is distinguished from Addiction by the appearance of tolerance and withdrawal, leading to loss of control over use. Substance abusers require motivation to stop. Addicts require treatment to stop.

  7. Entrance into System Arrest Psych Emergency Emergency Room Assessment Domestic Violence Family Court Probation - Parole Schools

  8. Monitoring and Treatment In-custody Treatment Residential Treatment IOP + Sober Living Intensive Outpatient IOP Addict Re-entry Monitoring Random UDS 6 months (Positive UDS) Entry Assessment Monitoring Random UDS 6 tests/90 days ? Discharge Unsure Discharge

  9. National Survey on Drug Use and Health Statistics 2007

  10. Prescription Drug Abuse Opiate pain medications Benzodiazepine tranquilizers Prescription stimulants (Adderall, Ritalin) Sleeping pills, muscle relaxants

  11. Sentinel Events in Prescription Drug Abuse Overdoses in younger individuals DUI arrests with low BAL Youth falling asleep in school Youth stealing from parents and friends Increased schoolyard drug and pill sales

  12. National Survey on Drug Use and Health Statistics 2007

  13. National Survey on Drug Use and Health Statistics 2007

  14. “You’ve Got Drugs V” Prescription Drug Pushers on the Internet. National Center on Addiction and Substance Abuse, Columbia University 2008

  15. Prescription Opiates Generic: Brand Name Non Tolerant 24 hr. dose Codeine w/acetaminophen 500 mg Hydrocodone:Vicodin, Lortab, Norco 20mg-60 mg Hydromorphone: Dilaudid 20 mg-60 mg Oxycodone: Percodan, OxyContin 20 mg-60 mg Morphine sulfate: MS Contin 30 mg-60 mg Fentanyl: Duragesic (transdermal), Actiq 25 mcg-50 mcg Tolerant Users only Tolerant 24 hr. dose Morphine sulfate: MS Contin 60 mg-upward Fentanyl: Duragesic (transdermal) 75 mcg-300 mcg Methadone: Methadose 60 mg-300 mg Buprenorphine: Suboxone, Subutex 6 mg-32 mg

  16. Opiate progression from pills to the needle Historically, untreated dependence on prescription opiates led to a trajectory from • Pills ingested orally • Pills crushed and snorted or smoked • Heroin snorted or smoked • Heroin used intravenously

  17. A 33-year follow-up of narcotics addicts .

  18. Overview of Buprenorphine:Suboxone and Subutex • Highly safe medication (acute & chronic dosing). • Primary side effects: like other mu agonist opioids (e.g.,nausea, constipation) but may be less severe. • No evidence of significant disruption in cognitive or psychomotor performance with buprenorphine maintenance. • No evidence of organ damage with chronic dosing. Use of Buprenorphine in the Pharmacologic Management of Opioid Dependence: A Curriculum of Physicians. (eds: Strain EC, Trhumble JG, Jara GB) CSAT. 2001

  19. Prescription Tranquillizers Dose Equivalent To Alcohol (2oz liquor or 2 glasses of wine or 2 cans of beer) • Alprazolam (Xanax®) 0.5- 1mg • Diazepam (Valium®) 10mg • Chlordiazepoxide (Librium®) 25mg • Clonazepam (Klonopin®) 1-2mg • Lorazepam (Ativan®) 2mg • Temazepam (Restoril®) 30mg • Butalbital (in Fiorinal®) 100mg • Carisoprodol (Soma ®) 350mg • Zolpidem (Ambien®) 10 mg

  20. Effects Calm Euphoria Release of Inhibitions Sleep Inducing Sedation/Sleepiness Slurred Speech Unsteady gait (Ataxia) Confusion Forgetfulness Slows heart rate Decreases blood pressure * Symptom may continue for months Withdrawal Dysphoria * Anxiety * Insomnia * Sweating (Diaphoresis) * Tremor Tachycardia Hypertension Hyperventilation Elevated temperature Hallucinations Seizures Delirium tremens Sedative-Hypnotic Effects

  21. Prescription Stimulants Adderall is a brand-name pharmaceutical psychostimulant composed of mixed amphetamine salts. Adderall is widely reported to increase alertness, concentration and overall cognitive performance while decreasing user fatigue. Prescription Stimulants are Schedule II drugs under the Controlled Substance Act for the United States. Concerta, Vyvanse, Dexedrine are similar, often abused, prescription psycho-stimulants.

  22. Antidepressants (anhedonia/anergia) Effexor XR 150-300 mg Cymbalta 60 mg Wellbutrin XL 150-300 mg Desipramine 100-200 mg Anti-Craving Medications Modafinil 100-200 mg Methylphenidate LA 10-40 mg Buproprion 150-300 mg Concerta 18-54 mg Dexedrine SR 20-30 mg Disorders of Sleep Trazedone 50-300 mg Seroquel 25-100 mg Imipramine 100-200 mg Disorders of Thought Abilify 2-10 mg Haldol 1-2 mg Risperdal 1-3 mg Medications for Stimulant Dependence

  23. Are you at Risk? B P S M The Bio-Psycho-Social Model E W M S Environment Withdrawal Mental Health Stress

  24. Bio-Psycho-Social Model • Predisposition Genetics Childhood Sexual Abuse Mental Illness Acquired Hypofrontality in utero alcohol/drug exposure low birth weight perinatal asphyxia head injury • The Drug / Circumstances of First Use • Enabling System

  25. C I M Model TreatmentCauses of Craving E W M S • Environmental cues (Triggers) immediate, catastrophic, overwhelming craving stimulated by people, places, things associated with prior drug-use experiences • Drug Withdrawal inadequately treated or untreated • Mental illness symptoms inadequately treated or untreated • Stress equals craving

  26. Environmental Cueing =Conditioned Craving Drug pleasure becomes associated with specific people, places, and things; to encounter any of those things in the environment is to trigger craving for the drug. Such triggers persist for decades after use.

  27. Bio-Psycho-Social ModelAre you at Risk? Apply B P S M (bio-psycho-social model) to yourself: Family history of addiction? Do you have a tendency to boredom or ADHD? Are you anxious or depressed? Have you suffered sexual trauma? Do you use substances to reduce stress? Did drug and alcohol use enter your life at a difficult time? Are you surrounded by drug and alcohol users?

  28. Bio-Psycho-Social ModelAre you in trouble? How can you tell if you are getting into trouble? Are you using more frequently and using greater amounts? Have you developed tolerance? Is your use causing adverse consequences: grades, friends, money, health, unwanted sexual behavior? Do you crave the drug under addiction conditions: Environment, Withdrawal, Mental Health, Stress (EWMS) If so, when you crave the drug, can you talk yourself into using it, even when you have resolved to not use? When you have resolved not to use, under known craving conditions, do you find yourself using: environmental cues, anxiety or blue, withdrawal (bored, irritable, sleep), or when you are stressed?

  29. TRY THE “EXPERIMENT” Resolve not to use for 5 weeks. Go about your usual daily activities. Put yourself around the drug and people using it. Bio-Psycho-Social ModelAre You an Addict?

  30. AFTER 5 WEEKS Were you able to not use? Did you find your mind talking you into using? Did you struggle not to use? Were you able to have pleasure without using? Did you have problems with boredom, depression or anxiety? Bio-Psycho-Social ModelAre You an Addict?

  31. Bio-Psycho-Social ModelWhat to do Get out of the using environment. Find alternative sources of pleasure. Work on balancing stress. Seek help for mental health issues and other personal stresses.

  32. Inherited predisposition (genetics) Childhood trauma or abuse Unwanted sexual involvement before age 13 Mental Illness: depression, anxiety, personality disorder Attention Deficit Disorder (ADD) Learning disabilities/school failure Subjected to teasing, bullying Acne and/or obesity Other than heterosexual orientation Social rejection Early sexual involvement Onset of drug use before age 16 Enabling environment Ignorance No family history of addiction Good mental health Academic competence Positive relationship with an adult Family eats dinner together 5 days/wk Peer group participation (clubs) Participation in sports Participation in music, drama or dance Involvement in faith-based activities Taking care of pets Volunteer activities Social acceptance Environment disapproves of drug use Immediate, appropriate scaled consequences for alcohol/drug use. Early intervention for alcohol/drug use Addiction: Risk & Resilience

  33. REFERENCES • --- Responsibility and choice in addiction. Psychiatric Services. 53(6):707-13 (2002). • Bechara A. Decision making, impulse control and loss of willpower to resit drugs: a neurocognitive perspective. Nature Neuroscience. 8:1458-63 (2005) • Dackis C, O’Brien C. Neurobiology of addiction: treatment and public policy ramifications. Nature Neuroscience. 8(11):1431-6 (2005). • Nestler EJ, Malenka RC. The addicted brain. Scientific American.com February 9, 2004. • Stalcup SA, Christian D, Stalcup JA, Brown M Galloway GP. A treatment model for craving identification and management. Journal of Psychoactive Drugs. 38:235-44, 2006 • Volkow ND, Fowler JS, Wang GJ. The addicted human brain: insights from imaging studies. The Journal of Clinical Investigation. 111(10:1444-51 (2003). • Weinberger DR, Elvevag B, Giedd JN. The adolescent brain: a work in progress. National Campaign to Prevent Teen Pregnancy. June 2005.

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