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Addiction Medicine: Orientation to the Science of Addiction or An experienced addictionist reflects on applying science to service in a peer driven homeless shelter environment. October 21, 2010 Medical Director Panel Al J. Mooney MD Medical Director, The Healing Place of Wake County

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Addiction Medicine: Orientation to the Science of Addiction orAn experienced addictionist reflects on applying science to service in a peer driven homeless shelter environment

October 21, 2010

Medical Director Panel

Al J. Mooney MD

Medical Director, The Healing Place of Wake County

Chairman, Willingway Foundation

Associate Clinical Professor of Family Medicine, UNC Chapel Hill


Discussion point 1
Discussion point #1

  • Solving America’s #1health problem

  • Alcoholism and drug dependency conditions are major contributors to morbidity and mortality in mental health and physical health environments


Discussion point 2
Discussion point #2

  • “If a tree falls in the woods and nobody is there, does it make a noise?”

  • Knowledge of recent addiction science and neuroscience strengthens our understanding of addictive illness and recovery


Discussion point 3
Discussion point #3

  • “Walk a mile in my shoes”

  • Peer and mutual support (AA, NA, 12 step work, and mutual support) are promising to be effective bridges to life-long addiction recovery


Discussion point 4
Discussion point #4

  • “S*** happens”

  • Understanding that life-long recovery exists in three phases (or zones) assists an individual establish healthy sobriety and negotiate good and bad times throughout their recovering life


Putting it all together
Putting it all together

There is a problem

We can identify the problem

There is a free solution

We can connect the free solution with the problem


Where science meets the sickness

Where science meets the sickness

What evidence is there that the alcohol and drug problem is the number one health problem in America?


Disease facts the problem
Disease facts – The problem

  • Fatal illness

    • 100,000 deaths annually

    • YPLL = Cancer + Heart Disease

    • >80% unanticipated deaths in community mental health

  • Number 1 Health problem

    • $466 billion annual cost of NOT treating

    • No claims data to use for policy formulation

  • 7% U.S. population afflicted

  • ¼of hospital admissions

  • Family morbidity 43% (76,000,000)

  • 100% increase in healthcare costs

  • Primary cause of preventable birth defects

  • Treatment yield of $7 for $1 expense

  • $39 Yield for each $1 spent in medical settings

  • Prevention reduces risk by 75%


How to be blinded by the evidence
How to be “blinded by the evidence”

  • Scientific methods are being used in ways that corrupt measurement of meaningful outcomes

    • Adjust length of study to misrepresent outcome

    • Measure effects that justify use of medication

    • Avoid measurement of side effects

    • Emphasize statistical endpoints not relevant to clinical efficacy

    • Pay researchers to publish positive outcomes

    • Don’t report negative results

    • Publish research ghostwritten by marketing staff under physician bylines

    • Avoid comparison with alternatives known to be effective


Suicide 1950 2005
Suicide (1950-2005)

Sources: Centers for Disease Control and Prevention, National Center for Health Statistics. From Health, United States, 2005




Settlements for illegal or unethical drug marketing practices
Settlements for illegal or unethical drug marketing practices

  • Astra Zeneca $520,000,000

    • http://www.astrazeneca-us.com/about-astrazeneca-us/newsroom/8936389?itemId=8936389

  • Pfizer $2,300,000,000

    • http://www.ama-assn.org/amednews/2009/09/14/prl20914.htm

  • Purdue Pharma $634,500,000

    • http://www.nytimes.com/2007/05/11/business/11drug.html?_r=1&scp=1&sq=Purdue%20Pharma%E2%80%99s%20May%2011%20plea%20agreement%20&st=cse

  • Lilly $1.400,000,000

    • http://www.bmj.com/content/338/7688/News.full.pdf

http://www.taf.org/top20.htm


Drinking behavior in america
Drinking behavior in America practices

  • ⅓ nondrinkers

  • ⅓ occasional drinkers

  • ⅓ regular drinkers (high alcoholism risk)

  • >50% consumption by 6% adults


Disease facts the problem1
Disease practicesfacts – The problem

  • Fatal illness

    • 100,000 deaths annually

    • YPLL = Cancer + Heart Disease

    • >80% unanticipated deaths in community mental health

  • Number 1 Health problem

    • $466 billion annual cost of NOT treating

    • No claims data to use for policy formulation

  • 7% U.S. population afflicted

  • ¼of hospital admissions

  • Family morbidity 43% (76,000,000)

  • 100% increase in healthcare costs

  • Primary cause of preventable birth defects

  • Treatment yield of $7 for $1 expense

  • $39 Yield for each $1 spent in medical settings

  • Prevention reduces risk by 75%


Attributable morbidity
Attributable morbidity practices

  • 38% automobile fatalities

  • 5X risk of vehicle fatality

  • 20% suicides

  • 65% drownings

  • 70% crises in MH setting requiring institutionalization

  • 16X risk of fall mortality

  • 10X risk of fire/burn victim

  • 31% boating fatalities

  • 40% industrial fatalities


History of alcoholism
History of alcoholism practices

  • Ancient alcohol problems (Bible, Aristotle)

  • Alcoholic individual (Seneca)

  • Economics of alcohol and drugs

  • Native American fellowship circles

  • Progression of alcoholism (Benjamin Rush)

  • Washingtonian movement

  • Temperance movement


Benjamin rush 1746 1813
Benjamin Rush (1746-1813) practices

  • An Inquiry into the Effects of Ardent Spirits upon the Human Body and Mind, with an Account of the Means of Preventing and of the Remedies for Curing Them, New York, 1811



Abraham flexner 1866 1959
Abraham Flexner William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"(1866 - 1959)

  • "It seemed to me the time was ripe for the creation in America of an institute in the field of general scholarship and science...where everyone -- faculty and members -- took for granted what was known and published, and in their individual ways endeavored to advance the frontiers of knowledge.“                                               


Carl jung
Carl Jung William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

  • Carl Jung (1875-1961) was a Swiss psychiatrist, an influential thinker and is renowned as the founder of analytical psychology. 

  • “Every form of addiction is bad, no matter whether the narcotic be alcohol, morphine or idealism.”


Doctor bob and bill w
Doctor Bob and Bill W. William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"


Jellinek symptoms of alcoholism
Jellinek symptoms of alcoholism William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

Social Drinking

Relief Drinking

Seek Drinking events

Tolerance

Psychological escape

Prodrome

Heavy Drinking

Blackouts

Gulping/sneaking drinks

Chronic hangovers

Crucial phase

Loss of control

Excuses

Eye-openers

Changing patterns of drinking

Antisocial behavior

Loss of friends, family, job

Medical and mental problems

Chronic phase

Benders

Tremors

Protecting supply

Resentments

Nameless fears and anxieties

Collapse of alibi system

Surrender


Drug types
Drug types William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

Alter our perception of reality

Alter a disease


Example benadryl
Example: Benadryl William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

Help allergy symptoms


Example benadryl1
Example: Benadryl William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

Sedation or antianxiety = relapse risk

Help allergy symptoms


Example morphine
Example: Morphine William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

Euphoria or high = relapse risk

Assist heart pumping


Drugs of abuse
Drugs of abuse William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

Stimulants

Narcotics

Other

Sedatives


Drugs of abuse1
Drugs of abuse William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

Ice

Ritalin

Crack

Adderal

Crystal Meth

Ultram

Methadone

Special K

Benadryl

Buprenorphine

Marijuana

Glue

Heroin

LSD

Prozac

Codiene

Peyote

Paxil

Morphine

PCP

Zoloft

Dextromethoraphan

“T”

Alcohol

Xanax

Butalbital

Ativan

Restoril

Chloral Hydrate

Valium

Methaqualone

Klonopin

Soma

Ambien


Alcohol effect on brain
Alcohol effect on brain William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"

< 0.05% Prefrontal Cortex

disinhibition

> 0.05% Amgdyla

emotional

>0.10% Cerebellum –

ataxia

>0.20% RAS

hypnosis

>0.30% Medulla -

Respiratory depression and death


The doctor s theory that we have an allergy to alcohol interests us alcoholics anonymous p xxiv
“The doctor’s theory that we have an allergy to alcohol interests us.”Alcoholics Anonymous p. XXIV

  • The alcoholic’s brain responds to chemicals and life differently than the brain of a normal individual. Multiple factors contribute to the development of addictions, but the total cause is still unknown to science.


Tolerance and dependence
Tolerance and dependence interests us.”

CNS Activity

Time


Tolerance and dependence1
Tolerance and dependence interests us.”

CNS Activity

Time


Tolerance and dependence2
Tolerance and dependence interests us.”

CNS Activity

Time


Tolerance and dependence vs addiction

CNS Activity interests us.”

Time

Tolerance and dependence vs. addiction


Addictive cycle
Addictive cycle interests us.”

1. Physical Allergy

2. Mental Obsession


Identification of alcoholism
Identification of alcoholism interests us.”

  • Drinking in spite of adverse consequences


Recognition old timer s question
Recognition – old timer’s question interests us.”

  • “Can you always predict how much or how long you will drink and/or use before you start?”


Natural rewards survival urges nutrients
Natural rewards interests us.” survival urges (nutrients)

  • Air

  • Food

  • Water

  • Sex

  • Intimacy (connectedness)


Brain regions
Brain regions interests us.”



Brain regions emotions
Brain Regions – Emotions interests us.”




Neurotransmitters
Neurotransmitters interests us.”


Reward pathway
Reward Pathway interests us.”


Addiction brain
Addiction Brain interests us.”


Addiction cascade
Addiction Cascade interests us.”

Drink

Drunk

Use again

“Trouble”

Abstain

Switch Chemical

or beverage

Urge to use


Addiction cascade1
Addiction Cascade interests us.”

Drink

Drunk

Self-deception

(Denial)

Abandon values

Use again

“Trouble”

Abstain

Switch Chemical

or beverage

Urge to use


Addiction is progressive

Death interests us.”

Disability

Diagnosable

Symptoms

Time

Addiction is progressive

Severity

Onset


Addiction is progressive1

Death interests us.”

Disability

Diagnosable

Symptoms

Time

Addiction is progressive

Severity

Onset


Addiction is progressive2

Death interests us.”

Disability

Diagnosable

Symptoms

Time

Addiction is progressive

Severity

Onset


Addiction and health nationally brain science
Addiction and health nationally: Brain science interests us.”

  • Neuroplasticity

  • Survival function of brain

  • Brain mapping

  • Executive function

  • Abstinence


Evidence based medicine
Evidence based medicine interests us.”

  • Science behavior change

  • MH/PC Integration

  • SBIRT

  • Peer methodology


Identifying the problem drinking in america
Identifying the problem interests us.”Drinking in America


Motivational readiness
Motivational Readiness interests us.”

Maintenance

Action

Preparation

Contemplation

Precontemplation


Clinician s guide helping people who drink too much
Clinician’s Guide – Helping People Who Drink Too Much interests us.”

  • Do you sometimes drink alcohol?


Single question screening
Single question screening interests us.”

  • Ask:

    • “In the past year how many times have you had 5 drinks or more in a 24 hour period of time?” (4 for women)

  • If greater than 0:

    The “risky drinker” needs intervention/treatment

    • Call peer recovery volunteer


History of angel calls
History of “Angel Calls” interests us.”

  • 1935 – Mutual support recovery and 12th step work

  • 2001 – Department of Surgery U of L collaborates with The Healing Place

  • 2004 – Rick Blondell investigates with inpatient clinical trial methodology

  • 2006 – North Carolina replication of a similar community model in a public mental health system

  • 2008 – Other replications in NC and acute care


“Carry this message to other alcoholics!……Life will take on new meaning.”Alcoholics Anonymous p. 89“You should not hesitate to visit the most sordid spot on earth”Alcoholics Anonymous p. 102

  • Taking a message of recovery to others is powerful for the messenger and the recipient and has few risks.


Peer support specialist domains of training
Peer support specialist take on new meaning.”Domains of training

  • Relationship building

  • Professional responsibility

  • System Competency

  • Addiction and recovery knowledge


Recovery expectations
Recovery expectations take on new meaning.”

Stop smoking

Spend time with spouse

Get blood pressure checked

Go to A.A. meetings

Call your sponsor

Sober up

Get cholesterol checked

Desire to stop

Get a sponsor

Clean out the attic

Get a checkup

Get more productivity at work

Eat right

Detox

Work the Steps

Support your Family

Improve your Spiritual life

Carry recovery message in community

Exercise more

Learn about good eating

Make amends list

Read the Big Book

Do an Inventory

Get a Job

Help others

Improve your relationships

Make amends

Go to church

Learn to have healthy fun

Study the Big Book

Report to monitor

Spend time with friends

Spend time with the kids

Do something about emotional problems


Neurophysiology of recovery
Neurophysiology of Recovery take on new meaning.”

  • Extended withdrawal for years

  • Structural and functional brain abnormalities


Relapse factors
Relapse factors take on new meaning.”

  • Use of a mood-altering chemical

  • Failure to adhere to effective recovery activities

  • Avoiding “rigorous honesty”


Willingway program truths
Willingway program truths take on new meaning.”

  • Cause of alcoholism and addiction is unknown

  • The active addictive cycle includes chemicals

  • The illness effects the total person: physical, mental, family, and spirit

  • Cross-addiction exists


Promote success in recovery by engaging and linking its phases
Promote success in recovery by engaging and linking its phases:

  • First, save your life

  • Next, do something worthwhile with it

  • Finally, live as long as you can

The Recovery Book


Recovery phases or zones

Phase I. Salvage life phases:

Phase II. Make life worthwhile

Phase III. Prolong life

Safety Zone

Work Zone

Comfort Zone

Recovery phases or zones


Zones in the recovery timeline
Zones in the recovery timeline phases:

Initial recovery

Reconstruction

Terminal illness

Years


Safety danger zone
Safety/Danger zone phases:

  • Engagement of the recovery process

  • From honest desire to stop until “Recovered”

  • Recipe from others (steps 1-9)

  • Honesty, open-mindedness, willingness

  • Mood altering Medications as “tools”

  • Accountability and consequences for motivation


Drug toxicity
Drug toxicity phases:

  • Development

  • Physical

  • Psychological

  • Frontal lobe damage

  • Hard rewiring necessary (9-12 months)

    • Judgment, insight, emotional dampening

Years


Work zone
Work zone phases:

  • From “promises” to completion of below

  • Maintenance steps (10, 11, 12)

  • Multiple choice

  • (Re)construction of:

    • Family and relationships

    • Education and career

    • Recreation and hobbies


Comfort zone
Comfort zone phases:

  • Until unmet needs from previous phases emerge

  • Mutual support leadership

  • Attend to life limiting issues

  • Share experiences in recovery

  • Break the generational cycle

  • Advocate for those still suffering

  • Visible recovery


Summary
Summary phases:

  • Most recover with proper motivation and treatment

  • Recovery happens in phases

  • Application of the principle of “Zones” will improve length and quality of recovery


The recovery book
THE RECOVERY BOOK phases:

Al J. Mooney MD

509 Midenhall Way

Cary, NC 27513

Mobile: 919 238 9349

Email: [email protected]


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