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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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slide1
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
  • ⅓ nondrinkers
  • ⅓ occasional drinkers
  • ⅓ regular drinkers (high alcoholism risk)
  • >50% consumption by 6% adults
disease facts the problem1
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%
attributable morbidity
Attributable morbidity
  • 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
  • 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)
  • 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
slide25
Medically-trained Harvard psychologist and philosopher William James (1842 - 1910) took an active and supportive interest in what he called "The Religion of Healthy-Mindedness"
abraham flexner 1866 1959
Abraham Flexner (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
  • 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.”
jellinek symptoms of alcoholism
Jellinek symptoms of alcoholism

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

Alter our perception of reality

Alter a disease

example benadryl
Example: Benadryl

Help allergy symptoms

example benadryl1
Example: Benadryl

Sedation or antianxiety = relapse risk

Help allergy symptoms

example morphine
Example: Morphine

Euphoria or high = relapse risk

Assist heart pumping

drugs of abuse
Drugs of abuse

Stimulants

Narcotics

Other

Sedatives

drugs of abuse1
Drugs of abuse

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

< 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

CNS Activity

Time

tolerance and dependence1
Tolerance and dependence

CNS Activity

Time

tolerance and dependence2
Tolerance and dependence

CNS Activity

Time

addictive cycle
Addictive cycle

1. Physical Allergy

2. Mental Obsession

identification of alcoholism
Identification of alcoholism
  • Drinking in spite of adverse consequences
recognition old timer s question
Recognition – old timer’s question
  • “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 survival urges (nutrients)
  • Air
  • Food
  • Water
  • Sex
  • Intimacy (connectedness)
addiction cascade
Addiction Cascade

Drink

Drunk

Use again

“Trouble”

Abstain

Switch Chemical

or beverage

Urge to use

addiction cascade1
Addiction Cascade

Drink

Drunk

Self-deception

(Denial)

Abandon values

Use again

“Trouble”

Abstain

Switch Chemical

or beverage

Urge to use

addiction is progressive
Death

Disability

Diagnosable

Symptoms

Time

Addiction is progressive

Severity

Onset

addiction is progressive1
Death

Disability

Diagnosable

Symptoms

Time

Addiction is progressive

Severity

Onset

addiction is progressive2
Death

Disability

Diagnosable

Symptoms

Time

Addiction is progressive

Severity

Onset

addiction and health nationally brain science
Addiction and health nationally: Brain science
  • Neuroplasticity
  • Survival function of brain
  • Brain mapping
  • Executive function
  • Abstinence
evidence based medicine
Evidence based medicine
  • Science behavior change
  • MH/PC Integration
  • SBIRT
  • Peer methodology
motivational readiness
Motivational Readiness

Maintenance

Action

Preparation

Contemplation

Precontemplation

single question screening
Single question screening
  • 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”
  • 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
slide70
“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 Domains of training
  • Relationship building
  • Professional responsibility
  • System Competency
  • Addiction and recovery knowledge
recovery expectations
Recovery expectations

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
  • Extended withdrawal for years
  • Structural and functional brain abnormalities
relapse factors
Relapse factors
  • Use of a mood-altering chemical
  • Failure to adhere to effective recovery activities
  • Avoiding “rigorous honesty”
willingway program truths
Willingway program truths
  • 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

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

Initial recovery

Reconstruction

Terminal illness

Years

safety danger zone
Safety/Danger zone
  • 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
  • Development
  • Physical
  • Psychological
  • Frontal lobe damage
  • Hard rewiring necessary (9-12 months)
    • Judgment, insight, emotional dampening

Years

work zone
Work zone
  • 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
  • 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
  • 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

Al J. Mooney MD

509 Midenhall Way

Cary, NC 27513

Mobile: 919 238 9349

Email: [email protected]

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