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Chemical Dependency a New Paradigm. Richard L. Hinchman, M.D., FACOG, FASAM. Your Brain on Drugs in the 1980’s. What the mind does not know, the eyes cannot see. If drugs and alcohol were the problem ……. 10. Animal Models. Alcohol (P) Preferring Mice Alcohol (NP) Non-preferring Mice.

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chemical dependency a new paradigm
Chemical Dependencya New Paradigm

Richard L. Hinchman, M.D., FACOG, FASAM

animal models
Animal Models
  • Alcohol (P) Preferring Mice
  • Alcohol (NP) Non-preferring Mice
human studies
Human Studies
  • PET scans of sons of alcoholic fathers
  • Sons were naïve to alcohol
  • 40% had lower Dopamine (DA) levels when compared to controls
quick review
Quick Review
  • Dependence is a Primary Disease
  • 40% to 60% genetic predisposition
  • Not located in judgment area of brain
  • Located in the mid-brain (survival)
  • Mid-brain controls the judgment area
  • DA Deficiency is underlying pathology
  • Treatment must maintain DA levels at the set point for survival
abuse vs dependence
Abuse vs. Dependence
  • Drug/Alcohol Abuse is a preventable behavior under the control of the PFC (judgment)
    • Normal DA levels in mid-brain
  • Drug/Alcohol Dependence is a treatable primary disease located in the mid-brain, (survival).
    • DA deficiency in mid-brain
alcohol abusers
Alcohol Abusers
  • 5-year follow-up of ~1,300 men & women
  • All met DSM-IV criteria for Abuse only
  • 5 years later only 3% met DSM-IV criteria for Dependence

Schuckit, M.A. et. al., Five year clinical course associated with DSM-IV alcohol abuse ……Am. J. Pshchiat. 158: 1084-1090

slide20
33.7% of all alcoholics who met DSM-IV criteria for Dependence…

Did not previously meet DSM-IV criteria for Abuse

NESARC 2001-02 study

genetic predisposition
Genetic Predisposition
  • 10% risk with no family history…..
  • 40% risk with one parent…..
  • 90+% risk with both parents….
chronic etoh consumption
Chronic ETOH Consumption
  • Chronic use of alcohol changes the genetic makeup of the neuron
  • Changes the structure of the receptor proteins, (D2 receptors)
  • Fewer D2 receptors for DA to bind to
  • Increased tolerance since more alcohol is required to get the same effect
slide23
The earlier a young person drinks ETOH, the more likely he/she will develop a clinically defined alcohol disorder later in life

Young people who begin drinking before age 15 are 4x more likely to develop alcoholism than those who wait until they are 21 to drink

NIAAA 2000

slide24
For each year an adolescent delays use of alcohol, he/she decreases the odds of lifelong dependence by 14%, and lifelong abuse by 8%

NIAAA January 2000

slide25

When Reading Emotion…

Adults Rely More on the Frontal Cortex

While Teens Rely More on the Amygdala

Deborah Yurgelon-Todd 2000.

social structure da levels
Social Structure & DA Levels
  • Altering social hierarchy in monkeys
  • PET scan measurements of DA levels
  • Higher social status had higher DA levels
  • Manipulation of the social hierarchy causing the higher levels monkeys to be moved to the lower levels….
  • DA levels decreased in their NAc
screening for at risk drinking
Screening for At-Risk Drinking
  • How many drinks containing ETOH do you consume per week? Per occasion?
  • Men: >14 drinks per week

> 4 drinks per occasion

  • Women: > 7 drinks per week

> 3 drinks per occasion

c a g e
C.A.G.E.

C: Have you ever tried to Cut down on your drinking?

A: Do you become Annoyed when people talk to you about your drinking?

G: Do you ever feel Guilty about your drinking?

E: Have you ever had an “Eye Opener” (a drink in the morning)

  • Positive screen if yes to 2 or more
c r a f f t adolescent screening
C.R.A.F.F.T.Adolescent Screening

C: Have you ever ridden in a Car driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

R: Do you ever use alcohol or drugs to Relax, feel better about yourself, or to fit in?

A: Do you ever use alcohol or drugs while you are Alone?

c r a f f t adolescent screening1
C.R.A.F.F.T.Adolescent Screening

F:Do you ever Forget things you did while using drugs or alcohol?

F:Do your Family or Friends ever talk to you about your drinking or drug use?

T:Have you gotten into Trouble while you were using alcohol or drugs?

“Yes” to 2 or more is predictive of a Substance Use Disorder

how does the alcoholic define alcoholism
How Does the Alcoholic Define Alcoholism?
  • The average alcoholic has a family, home, job & responsibility
  • Only 3% of alcoholics are the stereotype “skid row bums”
  • The alcoholic will continue to change his/her definition…
dsm iv substance dependence
DSM-IV Substance Dependence

>/= 3 of the following in a 12 month period

  • Tolerance
  • Withdrawal
  • Using larger amounts than intended
  • Persistent efforts to cut down or control use
  • Great deal of time spent getting the substance, taking it, & recovering
  • Important activities given up for using
  • Continued use despite psychological or physical problems caused by using the substance
slide34
Level I Individual counselling

Level II.1 Intensive Outpatient (IOP)

Level II.5 Partial Hospitalization

Level III.1-III.5 Non-hospital Residential

Level III.7 Inpatient Medically Monitored

Level IV General Hospital with ICU

Aftercare: Facilitated meetings to help

with reentry to family, work &

society (6-12 months)

twelve step recovery
Twelve Step Recovery

Robert L. Dupont, M.D.

  • 1st president of NIDA
  • 2nd U.S. Drug Czar
  • The Selfish Brain: learning from addiction
  • “The secret weapon in the war on drugs is the 12-Step program”
  • “12-Step programs are the key to long-term recovery”
  • “12-Step recovery is THE ONLY THING THAT WORKS”
georgia physician s study
Georgia Physician’s Study
  • At least five 12-Step meetings per week
  • Weekly Caduceus meetings
  • 77% success at 7 years
  • 76% of relapsers remained sober after 2 years with additional treatment
extended abstinence is predictive of sustained recovery
Extended Abstinence is Predictive of Sustained Recovery

After 5 years – if you are sober, you probably will stay that way.

It takes a year of abstinence before less than half relapse

Dennis et al, Eval Rev, 2007

incubation of relapse propensity over time
Incubation of Relapse Propensity Over Time
  • The longer an individual remains in their old “using” environment immediately after treatment, the greater the risk of relapse
  • This may be measured in days
slide39
Relapse

Prevention

3 different classes of relapse
3 Different Classes of Relapse
  • Stress mediated: (POMC)
  • “Cue” mediated (“euphoric recall”)
  • Drug mediated: (VTA-to-NAc)
    • Cross Addiction
    • Opiate Rx for legitimate pain
stress and relapse
Stress and Relapse
  • Pro-opio-melanocortic (POMC)
  • MSH + ACTH + beta-endorphin
  • Increases Dopamine levels in NAc
  • CRF antagonists significantly reduced alcohol consumption in alcohol (P) mice
cross addiction
Cross-Addiction
  • Mouthwash containing alcohol
  • Cough syrups containing alcohol
  • Benadryl
  • O’Doule’s (non-alcoholic beer)
  • Prescription Sabotage
prescription sabotage
Prescription Sabotage
  • Propoxyphene (methadone-related)
  • Talwin (opioid agonist-antagonist)
  • Ultram (central opioid agonist)
  • Provigil (narcolepsy, sleep apnea)
  • Lyrica
opiates and pain
Opiates and Pain
  • Opiates bind to Mu receptors
  • Inhibit the Mu receptors
  • Decrease in adenyl cyclase activity
  • Decrease in cyclic-AMP
  • Increase in K+ efflux
  • Decrease in Ca++ influx
  • Hyperpolarizationof the pain nerve fibers in the ascending & descending pathways resulting in a reduction of pain

Prolonged use of a short acting opiate reverses this cascade resulting in increased pain

prolonged opiate use denmark epidemiological study
Prolonged Opiate UseDenmark Epidemiological Study

Chronic opiate use for non-cancer pain relief

Denmark has the highest per capita use of opioids in the world

Eriksen, Bruera, et.al. Critical issues on opioids in chronic non-cancer pain. An epidemiological study. Pain 2006; 125: 172-179

patients reported
Patients reported:
  • Significantly more pain
  • Poorer self-rated health
  • Lower quality of life
  • Lower levels of physical activitiy
  • Lower levels of employment
  • Higher levels of health care utilization
increased mortality after treatment
Increased Mortality After Treatment
  • Mean time of inpatient treatment (54 wks)
  • Highest mortality occurred within the first four weeks after release from treatment
  • Fatal overdose was most common cause
  • Violence was second leading cause of death

Ravndal E. Amundsen EJ. Mortality among drug users after discharge from inpatient treatment: Drug Alcohol Depend. 2010;108(1-2):65-69

club drugs
Club Drugs:
  • Ecstasy
  • GHB
  • Rohypnol
  • Ketamine
  • K2, Spice
  • Huffing
ecstasy
Ecstasy
  • “XTC”, “X”, “Adam”, “hug”, “beans”, “love drug”
  • Causes mental stimulation and emotional warmth
ecstasy1
Ecstasy
  • Blocks reuptake of serotonin by nerve terminals
  • Depletes nerve terminals of serotonin
  • Malignant Hyperthermia
  • 2-D-6 enzyme deficiency
    • Occurs in 10% of the population
    • Same as increasing the dose 10x
slide60
GHB
  • “G”, “Liquid Ecstasy”, “soap”
  • Colorless clear liquid or powder
  • CNS depressant
  • Lethal dose very close to therapeutic dose
  • May result in sleep, coma, seizures & death
  • “date rape drug”
rohypnol
Rohypnol
  • “roofies”
  • Similar effect to Valium, Ativan & Xanax
  • Can produce anterograde amnesia
  • Combined with GHB
    • Cause unconsciousness & temporary blackout leaving the victim vulnerable to sexual assault with no memory of incident
  • Can produce tolerance, physical dependence and withdrawal seizures
ketamine
Ketamine
  • “Special K”, “Vitamin K”, “Jet”
  • Dissociative anesthetic used in veterinary medicine
  • Distorts perception of sight & sound
  • Potentially fatal respiratory problems
  • Users can develop tolerance & cravings
k2 spice jwh 018
K2, Spice, (JWH-018)
  • “legal marijuana”
  • Chemically not related to THC but binds to the Cb1 receptors in the brain
  • 20x more potent than marijuana
  • Extremely high BP, CVA, MI, coma, malignant hyperthermia & death
  • Distinctive odor (incense-like)
  • Tolerance & Withdrawal Syndrome
  • Sold legally at truck stops & head shops
slide68
Richard L. Hinchman, M.D., FACOG, FASAM

6756 McFarland Rd.

Indianapolis, IN 46227-7718

Cell: (317) 442-0123

Fax: (317) 786-7381

rasbc@aol.com