Addiction Medicine Update University of Florida - FSAM Scott Teitelbaum, M.D. Vice Chairman & Chief of Addiction Medicine , President
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Addiction Medicine Update
University of Florida
Scott Teitelbaum, M.D. Vice Chairman & Chief of Addiction Medicine , President
FSAM
1
NIMH’s Annual Report :
“Top 10 Research Advances of 2011”
6. Grand Challenges in Global Mental Health.
Mental, neurological, and substance use (MNS) disorders account for 13%
of the global burden of disease, more than cancer and cardiovascular
disease (15). It is becoming very clear that there is no health without
mental health and that without efforts to identify and treat the substance
abusers and mentally ill, more and more of the health dollars are spent
on Band-Aids and revolving doors. European Union and global recognition
of the economic costs of mental illness (17) and the importance of
including mental health in global health care (18, 19) is clear, but often
ignored and unfunded .
(15) World Health Organization. The Global Burden of Disease: 2004 Update (WHO, 2008).
(16) Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar AS et al. Grand challenges in global mental health. Nature. 2011 Jul 6;475(7354):27-30.
(17) Bloom DE, Cafiero ET, Jané-Llopis E, Abrahams-Gessel S, Bloom LR, Fathima S, Feigl AB, Gaziano T, Mowafi M, Pandya A, Prettner K, Rosenberg L, Seligman B,
Stein A, Weinstein C. The Global Economic Burden of Non-communicable Diseases. Geneva, Switzerland: World Economic Forum, 2011
(18) Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, Ntulo C, Thornicroft G, Saxena S. Scale up of services for mental health in low-income and
middle-income countries. Lancet. 2011 Oct 29;378(9802):1592-603.
(19) Raviola G, Becker AE, Farmer P. A global scope for global health--including mental health. Lancet. 2011 Nov 5;378(9803):1613-5.
3
5
UF College of Medicine
UF Division of Addiction
Medicine
Research
Clinical
Teaching
University of Florida is Leading The Nation
• Addiction-Related Brain Science
• Treatment Research
• Education
• Epidemiology & Toxicology
• Recovery Programs for Professionals
• Scholarly & Prevention Activities from
Gainesville to Beijing
UF Distinguished Alumni Professor
(2011-2013)
Addiction Medicine
Meet The Experts:
Division of Addiction Medicine
Detoxification Inpatient Treatment Partial Hospitalization Impaired Professionals Treatment
Outpatient Evaluation and Treatment Suboxone® Maintenance• 20 Addiction Researchers at UFCOM Led By
Mark S. Gold, MD
• Mark H. Lewis, PhD
• John M. Petitto, MD
• Nicole M. Avena, PhD
• Sara Jo Nixon, PhD
• Lewis R. Baxter, Jr., MD
• Habibeh Khoshbouei, PharmD, PhD
• Lisa J. Merlo, PhD
• Karen M. von Deneen, DVM, PhD
• Yijun Liu, PhD
• Firas H. Kobeissy, PhD
• Adriaan W. Bruijnzeel, PhD
• Barry Setlow, PhD
• Bruce Goldberger, PhD
• Drake Morgan, PhD
• Todd E. Golde, MD
• C. Shawn Dotson, PhD
• Sylvain Dore, PhD
• Marcelo Febo, PhD
• Kevin Wang, PhD
Updated
9/27/11Food Addiction and Obesity: Evidence from Bench
to Bedside
Liu Y, von Deneen KM, Kobeissy FH, Gold MS. Journal of Psychoactive Drugs, 2010; 42(2): 133-145.
• Associated with both substance
related disorder and eating
disorder
• Many shared neural and
hormonal pathways
• Distinct differences
• fMRIs of obesity and drugs of
abuse show same characteristics
• Acquired drive with respect to
motivation and incentive2012:Progress in Basic Addiction Science • Drugs Change the Brain Over Time- Prevention is the Best and only 100% Effective Rx • Early or Pediatric Exposure Makes Abuse and Dependence Most Likely- Cigarettes, Alcohol, Drugs • Genes are not destiny but do matter—how long from use until dependence; choice of drug or drugs; exposures as a child or in utero trump genes or may actually change them • Drugs Switch the Brain and Occasional Use Becomes Addiction or Dependence • Drugs Hijack the Brain—New Understanding & New Therapies Possible
ADDICTION IS A DISEASE OF THE BRAIN
As other diseases, it affects tissue function
Decreased Brain Metabolism in Drug Abuse Patient
High
Control Cocaine Abuser
Decreased Heart Metabolism in Heart Disease Patient
Low
Healthy Heart Diseased Heart
Sources: From the laboratories of Drs. N. Volkow and H. SchelbertDopamine D2 images of Drug Addiction
Control Abuser Control Abuser
Cocaine Heroin
Methamphetamine Control Abuser Alcohol Control Abuser
Drug abusers have low brain dopamine activity (shown here using [11C]raclopride PET
studies) indicating an under stimulated reward system.
National Institute on Drug Abuse. Addiction Science: From Molecules to Managed Care. Available at:
17
http://www.drugabuse.gov/pubs/teaching/teaching6/Teaching4.htmlThe Memory of Drugs
Amygdala Amygdala
Front of Brain not lit up activated
Back of Brain
Nature Video Cocaine VideoUF’s 2012 Addiction Research Highlights Dynamic cause-effect relationships between risky decision making and drugs of abuse Second and third hand Opium exposure compromises children in Afghanistan Novel lead compounds (5-HT(2C) agonist/5-HT(2A) inverse agonist) for drug development for obesity, addiction and neuropsychiatric disorders Identification of novel drug targets for treatment of RRB in autism Proteomic changes following second-hand smoke exposure Methamphetamine damages brain cells like head trauma does Development of nanotechnology for determination of alcohol/drug concentrations (e.g., exhaled breath to measure blood ethanol concentrations) Overlaps that exist in brain mechanisms that promote ingestion of food and drug abuse New pharmacological treatment for food addiction Long-term internet addiction and brain structural alterations
METH Use Neuronal Damage Similar to
Traumatic Brain Injuries
Accumulated evidence indicates that acute
administration of METH leads to neuronal
damage in several brain regions that is
similar to traumatic and ischemic brain
injuries via activation of calpain and
caspase proteolytic systems
METH exposure, like TBI can cause both
apoptotic and necrotic cell death
METH addicts might benefit substantially
from long-term rehabilitative approaches in
conjunction with neuroprotective agents
similar to those used in trauma patients.
Gold MS, Kobeissy FH, Wang KKW, Merlo LJ, Bruijnzeel AW, Krasnova IN, Cadet JL.
Methamphetamine- and trauma-induced brain injuries: Comparative cellular and molecular
neurobiological substrates. Biological Psychiatry 2009 Jul 15;66(2):118-127. 20International Collaborations/Global Health • Fogarty grant to provide behavioral health training in India and increase research opportunities between UF and Indian partners • Neuroimaging collaborations with Chinese investigators and China’s NSF • Canada Drugs and Children- Calgary • Second hand drug exposure: Afghanistan and Brazil
Tobacco Smoking • Target is the Brain • No one smokes for foul smelling clothes…or a cough…or bad breath…or cancer • Smoking is injecting a drug without a needle…rapid delivery of smoke containing nicotine and other drugs to brain targets • Filter is an oxymoron…accelerator is more like it • SHS is first hand smoke against your will • Smoking mother = huge increased risk of a smoking adolescent • Teen smoker= Lifelong , chronic relapsing , smoker MSG 22
Smoke > IV > IM sniff > oral
Withdrawal Syndromes Do Not Define Drugs of Abuse
or Addiction
MSG 24Addiction Is Not Withdrawal • Most pain patients on chronic treatment have withdrawal if they stop their medications, but few are addicts • Addiction is pathological attachment • Desire and motivation to take a drug • Compulsive Self Administration after initial use & Loss of Control • Continued Compulsive Use Despite Extreme Consequences • Continuous Thinking or Seeking of Drugs Even When They Are Unavailable • Librium treats alcohol withdrawal but not the alcoholic. MSG 25
VTA
Amphetamines
Opiates Alcohol
THC benzodiazepines
PCP barbiturates
Ketamine Nucleus
Nicotine accumbens
Dopamine PathwaysBiological Socio-cultural
The processes
that initiate and
maintain
alcoholism are
regulated by
interactions
among nerve
cells in the brain.
Influences susceptibility
to drug usage
Psychological
EnvironmentalNIH/NIDA
28Hypofrontality in Cocaine Dependent Patients
Reduced Metabolic activity at baseline in cocaine dependent subjects
29Drugs Attack the Prefrontal Cortex &
Dependence Consequences are related to
dysfunctions in the Prefrontal Cortex
• Unfortunately the Prefrontal Cortex is Critical
for :
• Decision-making
• Weighing of risks vs. rewards
• Assigning emotional valence to stimuli
• Suppressing limbic impulses
• Goal-directed behaviors
30Motivational Toxicity
Why work so hard for rewards if reward can be produced
by smoking, drinking or drugs?
Intense motivation is critical in the disease of addiction
Hierarchy of work-reward disrupted
Pathological attachment or ‘Fatal Attraction’
Brain is unprepared by evaluation for reward n demand or
cocaine
Drug effects persist “forever: in coded “bad learning” and
with relapse, re-addiction can occur very quickly. Our
Group has also shown some drugs cause brain cell
damage and loss too!
31Drug Use Trends
In 1962, only 2% of the U.S. population over
the age of 12 years had tried an illegal drug
By the mid 1980s, nearly 50% of the
population had experimented with an illegal
drug
National Survey Drug Use and Health (NSDUH) 2008. Available
at https://nsduhweb.rti.org
3234
Past Year Marijuana Use
40
35
30
25 2009
20
2010
15
10 2011
5
0
8th 10th 12th
UM NIDA Monitoring the Future Study
Updated 1/30/12Nov. 4, 2002
36Gateway Drug
Marijuana Use Linked with Increased Risk of
Motor Vehicle Crashes
• Greater the amount of marijuana in a
person’s urine, the greater the risk of
a car crash
• 28% of drivers who died in an accident
tested positive for non-alcohol drugs
(most commonly, marijuana)
• Marijuana use by drivers is associated
with a significantly increased risk of
being in a motor vehicle crash.
Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G. Marijuana Use and Motor Vehicle Crashes.
Epidemiologic Reviews. Advance Access published October 4, 2011.Drug and alcohol involvement in four types of fatal
crashes
Drivers who die in crashes test positive for drugs 25% of
the time (44,239 drivers; 24 states)
Fatal crash subtypes: failure to obey/yield; inattention;
speeding; seat belt misuse
Alcohol positives: 42% Drug positives: 24.9%
Most prevalent drug classes: cannabinoids 22.7%;
stimulants 22.5%; multidrug 14.9%
Romano E and Voas RB. Drug and alcohol involvement in four types of fatal crashes. J
Stud. Alcohol Drugs, 2011; 72:567-576.
40Marijuana Perceived Risk vs. Use
Marijuana Primary Substance of Abuse at Admission to U.S.
State Licensed or Certified Substance Abuse Treatment
Facilities, Ages 12 and Older, 1992-2008
18
16
14
12
10
PERCENT
8
6
4
2
0
YEARAnhedonia and Abstinence • Drugs produce sense of well being and euphoria • Drugs of abuse change the brains set point for reward and pleasure • Drug withdrawal produces depression and anhedonia MSG 45
46
Dopamine Pathways Serotonin Pathways
striatum
frontal hippocampus
cortex
Functions
substantia •mood
nigra/VTA
Functions
•memory
•reward (motivation) processing
nucleus
•pleasure, euphoria accumbens •sleep
•motor function •cognition
raphe
(fine tuning)
•compulsion
•perseveration
MSG 47
47Prescription Misuse, Abuse, &
Addiction
• More Emergency Room admissions
• More overdose deaths
• More problems with Poly Pharmacy
• More older Americans addicted to pain
medicines…many are still in pain
• More need for addiction treatment of teens to
elder adultsGeneration Rx • 18% of teens have abused Vicodin • 20% tried Ritalin or Adderall without Rx • 9% abused OTC cough syrup to get high • More teens had abused a prescription painkiller in 2004 than Ecstasy, cocaine, crack or LSD • April 21, 2005. Partnership for a Drug Free America. 17th annual study of teen drug abuse.
‘Prescription’ Drugs • 1 in 4 high school seniors report using psychoactive medication without medical supervision – Sedatives – Narcotics – Barbiturates – Amphetamines
Might Not Meet Today’s FDA
Standards52
53
Many Adolescents Report Prescription Drug Abuse
Data from 2005 National Survey on Drug Use and Health found 8.2% of
teenagers (12-17 years) report misusing at least 1 prescription drug in
the prior year. Opioids were most misused. N=18,678.
Schepis TS, Krishnan-Sarin S. J Am Acad Child Adolesc Psychiatry.
2008;47(7):745-754.
54.
Bailey JA, Hurley RW, Gold MS. Crossroads of Pain and Addiction. Pain Medicine. 2010; Wiley Periodicals, Inc.
• Few pain training programs offer
Crossroads of Pain significant experiential and didactic
and Addiction training in drug abuse and addiction
Patients with coexisting • Addiction medicine programs offer
addictive disorders and little training in pain management
chronic pain are • Patients with coexisting pain/addiction
common and represent have a decreased pain tolerance,
some of the most increased anxiety, depression and sleep
disturbances
difficult patients in the
field of medicine. • Collaboration of these two fields can
lead to successful management of
patients with coexisting chronic pain
and addictive disordersHigh School Survey
Annual Oxycontin Use
6
5
4
2009
3
2010
2
2011
1
0
8th 10th 12th
UM NIDA Monitoring the Future Study58
M.D.s Rarely Make A Diagnosis
University of Pennsylvania study :
Only 3% of patients in treatment for
addiction came because of a M.D.
referral
MSG 59Huge Public Health Problem
MDs Are Out of the Loop—and getting worse
Penn Addiction Referral Sources
Source of Addiction Referrals
1990 2004
Drug Courts, Police,
Criminal Justice 38% 59%
Employers/EAP 10% 6%
Welfare/CPS 8% 16%
Hosp/Phys 4% 3%
MSG 60Alcohol Screening by PCPs • < 1/3 of U Penn “alcoholic” inpatients were seen recently by their MD or health provider. Few, if any, were screened using a CAGE or other rapid assessment screen for alcohol or drug problem • Even if an alcoholic in need of treatment was found < 1/2 were given any intervention or referral Edlund MJ, et al. Med Care 2004;42:1158-1166.
Top Physician Reasons
for Not Screening
426 PCPs at the
Society of General Internal Medicine
1. Don’t know what to do 69%
2. No effective treatment 55%
3. Not really a medical problem 26%
4. No time 19%
A. Thomas McLellan, Ph.D. ONDCP and University of Pennsylvania. Personal
communication, 2008.UF COM Education • Undergraduate • Medical Students • Pas & Nurses • Interns & Residents • Fellowship
Mandatory Addiction Medicine at
UF
• Clerkship, Not Classroom
• Imagine learning how to deliver a baby by listening to
a lecture or reading
• Competencies only possible by seeing, learning,
doing, and improving intervention, interviewing,
diagnostic skills, detox, and treatment skills of the
MD
• The data on MD performance is a reflection of the
lack of actual experience they receive in addiction
medicineASAM-ABAM Recognizes UF
• “In the past, the specialty was very much targeted toward psychiatrists,” said Nora
D. Volkow, the neuroscientist in charge of the National Institute on Drug Abuse.
“It’s a gap in our training program.” She called the lack of substance-abuse
education among general practitioners “a very serious problem.”
• Institutions offering the one-year residency are St. Luke’s-Roosevelt Hospital in
New York, the University of Maryland Medical System, the University at Buffalo
School of Medicine, the University of Cincinnati College of Medicine, the University
of Minnesota Medical School, the University of Florida College of Medicine, the
John A. Burns School of Medicine at the University of Hawaii, the University of
Wisconsin School of Medicine and Public Health, Marworth and Boston University
Medical Center. The new accreditation comes courtesy of the American Board of
Addiction Medicine, or ABAM, which was founded in 2007 to help promote the
medical treatment of addiction. NY Times July 10, 2011Addiction Medicine Leadership Group Scott Teitelbaum, M.D. - Double Boarded Pediatrician and Addiction Medicine Vice Chairman , Chief of Addiction Medicine’s 12 full time MDs and FRC Medical Director. President of Florida ASAM , Committees at ASAM, one of only 10 ABAM GME Fellowships & one of 3 with NIAAA funding . National Expert, Evaluator PRN , IPN, 37 State Boards of Medicine & NY Yankees. Frequent national media expert and called as an expert to the White House .Built FRC from State to National prominence. Martha Brown, M.D. -Double Boarded Psychiatrist and Addiction Psychiatrist Formerly USF Dean, LSU Associate Professor & Head of Louisiana’s Impaired MD programs. PRN (Florida) Associate Medical Director (50% effort) working with all Florida Medical & Health Specialty Boards. Extensive work in La., Fl. and Southeast as an Impaired Nurse and MD evaluator and Nationally as an expert for Professional Sports , especially NFL and NBA. UF ‘ s Pain Fellowship GME Program Co-Director and Pain CME ; Professionalism and Mis-Prescribing Director. Regional Expert. Kevin Wandler, M.D. - Double Boarded Psychiatrist & Addiction Medicine Pioneering Anorexia Nervosa, Eating Disorders and Dual Disorders Evaluation & Treatment Expert Psychiatrist and then CMO for Remuda Ranch safely treating >10,000 patients National Expert, BOD for Eating Disorders Societies Academy for Eating Disorders, International Association of Eating Disorders Professionals, & Christian Psychiatry Mark S. Gold, M.D. - Distinguished Professor, Eminent Scholar, and Chairman of 80 Faculty UFCOM Department. Inventor, Researcher & Author of nearly 1,000 scientific papers, books, and commentary. Inventor with 15 patents including Clonidine, Dopamine Hypothesis , Obesity Rx & Medication Adherence . Distinguished Alumni Awards from Wash U, Yale, and UFL. UpToDate Editor, International Expert from WHO to China-Japan to NAS in 80s on Tobacco and today on Obesity. Contracted Long-Term Consultant Positions to Major Wall Street firms (Lehman, Goldman, Carlyle, Cressy) Regularly Quoted expert on new technologies in WSJ, Bloomberg, CNN, and Others this year alone. Founder of FRC and first Addiction Medicine hire at UF
Recovery • Evidence does not support fast brain recovery • Evidence from NIDA’s Director Nora Volkow, M.D. and others failed to show brain recovery after many months of “successful” treatment • While brain recovery can and does happen with abstinence, treatment, exercise, and diet…it takes years and not days
Normal Cocaine Abuser (10 Days) Cocaine Abuser (100 Days)
The Target is Always
The Brain, however…
The nucleus accumbens lighting upWhile science has taught us
that addiction is a hijacking of
the brain, recovery must
involve healing of the heart
and the soul.Drug Abuse Is a
“Treatable Disease”
Comparison of Relapse Rates Between
Drug Addiction and Other Chronic Illnesses
100%
Percent of Patients
80% 50%-70% 50%-70%
Who Relapse
40%-60%
60% 30%-50%
40%
20%
0%
Drug Addiction Type I Hypertension Asthma
Diabetes
Addiction. NIH News National Institutes of Health. Available at:
http://www.nih.gov/news/pr/mar2007/nida-07.htm. Accessed June 16, 2008.Similarities to Other Medical
Disorders
• Substance addiction comparable to asthma,
hypertension and diabetes.
• Risk of relapse highest during first 3-6 months.
• Length of time in treatment is key
• Patients respond best to a combination of self
help and behavioral interventions.
• Treatment of severe cases & dual disorders
requires experts but, improves outcomesDrug Abuse Is a
“Treatable Disease”
Comparison of Relapse Rates Between
Drug Addiction and Other Chronic Illnesses
100%
Percent of Patients
80% 50%-70% 50%-70%
Who Relapse
40%-60%
60% 30%-50%
40%
20%
0%
Drug Addiction Type I Hypertension Asthma
Diabetes
Addiction. NIH News National Institutes of Health. Available at:
http://www.nih.gov/news/pr/mar2007/nida-07.htm. Accessed June 16, 2008.What is recovery? A working definition from
the Betty Ford Institute
The Betty Ford Institute Consensus There is an unknown but very large number of individuals who have
Panel experienced and successfully resolved dependence on alcohol or other
drugs. These individuals refer to their new sober and productive lifestyle
as “recovery.” Although widely used, the lack of a standard definition for
this term has hindered public understanding and research on the topic
that might foster more and better recovery-oriented interventions.
To this end, a group of interested researchers, treatment providers,
recovery advocates, and policymakers was convened by the Betty Ford
Institute to develop an initial definition of recovery as a starting point
for better communication, research, and public understanding.
Recovery is defined in this article as a voluntarily maintained lifestyle
composed characterized by sobriety, personal health, and citizenship.
This article presents the operational definitions, rationales, and
research implications for each of the three elements of this definition.
Journal of Substance Abuse Treatment
2007; 33: 221-228.What is recovery? A working definition from the
Betty Ford Institute
The Betty Ford Institute Consensus Pane (Dr Gold was a member of this panel )
Journal of Substance Abuse Treatment , 2007; 33:221-228.
Recovery = a voluntarily maintained
lifestyle characterized by:
• Sobriety
– Early (1-11 months)
– Sustained (1-5 years)
– Stable (> 5 years)
• Personal health
– Physical
– Mental
– Social
– Spiritual
• Citizenship
– “Giving-back”
– Quality of lifeSetting the standard for recovery:
Physicians’ Health Programs
DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Journal of Substance Abuse Treatment, 2009; 36:159-171.
• 904 physicians admitted to 16
state PHPs studied for 5 years
Elements of success:
• Abstinence-based programs
• Frequent random tests for 5
years
• Close linkages to 12-step
programs
• Use of residential/outpatient
programs rated excellentMD Addicts: 5-Year Outcomes
Status of Medical Practice
Medical Status Completers, % Continuers, % Noncompleters, % Total Sample, %
(Last Known) (n = 448) (n = 199) (n = 257) (n = 904)
Working in
91.1 81.9 27.6 72.0
Medicine
Licensed/
2.9 6.0 10.1 5.6
Not Practicing
Not Licensed/
Suspended 2.2 6.5 31.5 11.5
License
Retired/
1.8 2.5 7.4 3.5
Left Practice
Died 0.7 0.0 11.3 3.5
Unknown 1.3 3.0 12.1 4.8
DuPont RL, et al. Setting the Standard for Recovery: Physicians Health Programs. The
Betty Ford Institute Meeting, Rancho Mirage, CA; October 3-4, 2007.Essential Ingredients of the
PHP Model
• Contingency management with positive
consequences for abstinence and active
intervention for any use of alcohol or other drugs
of abuse
• Frequent random drug testing
• Abstinence standard – drugs and alcohol
• Link to 12-step programs
• Active management of relapse
• Long-term continuing care and monitoring
• Focus on life-long recoveryChallenges • Increasing Rx misuse • Younger age of onset of use • More MJ smoking youth • Poly Drug, alcohol users teens • Dual Disorders • MDs role in Rx misuse • Aging Floridians and Addictions • Health Providers-MDs role in failure to Dx • ED-ERs role in failure to DX and intervene
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