Stalcup training 5908

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

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. Definition of Addiction

2000 Smoking Prevalence : 

2000 Smoking Prevalence 70% of all cigarettes smoked in the United States are consumed by people with psychiatric and/or substance abuse disorders. Smoking rates in schizophrenic individuals exceed 80%. Smoking rate in individuals with major depression and other mood and anxiety disorders is 41% Smoking rate in individuals with alcoholism, heroin dependence or other illicit drug use is 67.9% Smoking prevalence in the US in 2000 was 23.3%

Dual Diagnosis : 

Dual Diagnosis Mental Illness symptoms interact with drug effects. Intoxication: relieves symptoms of mental illness Tolerance: exacerbates symptoms of mental illness Withdrawal: exacerbates symptoms of mental illness

Prevalence of smoking in individuals with PD and SUD : 

Prevalence of smoking in individuals with PD and SUD

Nicotine and Alcohol : 

Nicotine and Alcohol Animal studies show that nicotine increases voluntary alcohol intake. 50% to 90% of alcohol-dependent individuals smoke regularly. Regular smokers consume more alcohol than nonsmoking alcoholic individuals. Alcoholic individuals who smoke continue to demonstrate a high level of nicotine dependence during abstinence from alcohol. Chronic cigarette smoking in alcoholic individuals is associated with significantly higher quantity and frequency of alcohol consumption compared with nonsmoking or former-smoking alcohol-dependent individuals. Alcoholic smokers have more severe nicotine dependence and greater difficulties quitting than nonalcoholic smokers. In a US cohort treated for alcoholism, mortality associated with cigarette smoking was 51%, whereas mortality related to alcohol-induced diseases alone was about 34%. More than 4 times as many Americans die from smoking-related than from alcohol-related causes.

Smoking Prevalence : 

Smoking Prevalence 75.5% ever smoked 63.3% smoked whole cigarette 42.8% ever smoked daily 21.7% ever nicotine dependent 14.1% current nicotine dependence 42.8% ever smoked daily  53.1% ever nicotine dependent  66.2% current dependence

Tobacco Dependence is a Pediatric Disease : 

Tobacco Dependence is a Pediatric Disease 80% of smokers have risk factors known in childhood Family history of addiction ADHD (attention deficit hyperactivity disorder) Mood disorder (depression, anxiety, trauma) School failure 89% of adult smokers try cigarettes before age 18 71% of adult smokers are regular smokers at age 18

Prenatal Nicotine Exposure in Rat Pups : 

Prenatal Nicotine Exposure in Rat Pups Fig. 1 ADHD Increased locomotion Fig. 2 ADDICTION Increased preference for cocaine Fig. 3 DEPRESSION Increased learned helplessness

Adjusted Odds Ratio for ADHD among US Children by Prenatal Tobacco Exposure and Sex : 

Adjusted Odds Ratio for ADHD among US Children by Prenatal Tobacco Exposure and Sex

What is a Drug? : 

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

Neuroadaptation : 

Neuroadaptation In direct response to overstimulation, brain regions decrease in sensitivity and responsiveness. Brain regions become unresponsive (“deaf”) to usual levels of stimulation, a process by which the reward and pleasure centers of the brain adapt to high concentrations of pleasure neurotransmitters (tolerance). 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. In addition to pleasure neuroadaptation, other brain pathways stimulated by drugs also become under active, directly leading to anxiety, depression, and loss of energy. Once neuroadapted, the pleasure system remains impaired for months to years, interfering with sobriety, learning, and impulse inhibition.

Principles of Addiction Biology : 

Principles of Addiction Biology Drugs and alcohol activate the pleasure-producing chemistry of the brain and the brain circuits that govern calm and alertness. Over-stimulation of brain circuits causes them to neuroadapt which interferes with the normal experiences of pleasure, calmness and alertness. Addiction is a disease of the pleasure-producing chemistry of the brain and related brain circuits; Overstimulation causing neuroadaptation is the mechanism of the disease. Transition to addiction from substance abuse arises from the development of tolerance and withdrawal. With neuroadaptation, cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless and without energy.

Environmental Cueing = Conditioned Craving : 

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.

Slide 17: 

Behavior Control: The Balance Concept Greed Lust Fear Rage Jealousy Hunger Midbrain Forebrain Decision Making Logic Judgment Ethics Salience (weighing value) Drug Craving Weighing consequences Cueing

D2 Hypofrontality : 

D2 Hypofrontality Baseline metabolism falls in the prefrontal cortex secondary to decreased excitatory dopamine input. Impaired decision making results from direct interference with reasoning, logic, and the ability to weigh consequences. Drives, impulses, and craving are not inhibited because of direct compromise of brain reasoning ability. The mind overvalues reward, fails to appreciate risk, and fails to activate systems that warn of impending danger. The mind misjudges using as “worth it” by being unable to appreciate adverse consequences.

Addiction Pathophysiology : 

Addiction Pathophysiology Hedonic Dysregulation Dysphoria Persistent boredom Drug hunger D2 Hypofrontality Decreased recall of adverse consequences Over value reward -- Under value risk Impaired impulse control Conditioned Craving Drug-Specific Neural Dysregulation Alcohol / benzodiazepines: anxiety, insomnia, hypertension Opiates: pain, anxiety, insomnia

Nicotine EffectsReceptor Activation : 

Nicotine EffectsReceptor Activation Increase arousal Heighten attention Influence stages of sleep Produce states of pleasure Decrease fatigue Decrease anxiety Reduce pain Improve cognitive function

Nicotine Receptor Activation : 

Nicotine Receptor Activation

Brain Circuit Neuroadaptation : 

Brain Circuit Neuroadaptation Over-stimulation causing neuroadaptation affects all brain circuits. Each drug type affects specific circuits, in addition to pleasure circuits. Drug-specific circuits cause a mixture of sedation and stimulation (intoxication). Once neuroadaptation develops (tolerance), there will always be withdrawal symptoms that are the mirror image of the drug effects. With neuroadaptation, cessation of drug use leads to ‘inversion of the high’; sobriety becomes pleasureless, anxious, sleepless, and lacking energy

Nicotine EffectsWithdrawal Symptoms : 

Nicotine EffectsWithdrawal Symptoms Mentally sluggish Inattentive Insomnia Boredom and dysphoria Fatigue Anxiety Increase pain sensitivity Worsen cognitive function

Differences in Neuroadaptation between Nicotine and other Addicting Drugs : 

Differences in Neuroadaptation between Nicotine and other Addicting Drugs Tolerance to most drugs develops over weeks to months and resolves in months to years. Tolerance to nicotine develops over a single day and resolves over night.

Model for nicotine addiction cycle during daily cigarette smoking. : 

Model for nicotine addiction cycle during daily cigarette smoking.

RISK OF ADDICTION : 

RISK OF ADDICTION Positive and Negative Reinforcement If, in addition to producing pleasure (positive reinforcement), a drug is more addicting if it relieves negative states: boredom, anxiety, depression or stress (negative reinforcement).

Bio-Psycho-Social Model : 

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

Addiction: Risk & Resilience : 

Addiction: Risk & Resilience 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

Smoking Trajectories of Adolescent Novice Smokers : 

Smoking Trajectories of Adolescent Novice Smokers 72.4% Did not progress to addiction School has clear rules on smoking 27.6% Did progress to addiction Development of nicotine dependence Poor academic performance More than half of friends smoke Students smoke despite school rules Parents smoke nicotine Teachers/staff smoke near school Co-morbidity highly prevalent 11.1% Slow Use Escalation Female gender 10.8% Moderate Use Escalation Female gender 5.7% Rapid Use Escalation Male gender High co-morbidity Strong family history for addiction

Goals of Assessment : 

Goals of Assessment Is the client an addict? Evidence of out of control use, in the face of adverse consequences, driven by craving and facilitated by denial. What combination of factors in the Bio-psycho-social model led to addiction? Genetics, mental illness, sexual trauma, hypofrontality, enabling system. What four causes of craving perpetuate the addiction? Environment, withdrawal, mental illness, stress What are the barriers to sobriety? Generation of a Treatment Plan

Are you at Risk? : 

Are you at Risk? Apply the bio-psycho-social model to yourself: Do you have a 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 have an effective way to manage stress?

Are you in trouble? : 

Are you in trouble? How can you tell if you are getting into trouble? Are you compulsive? Is use causing adverse consequences? Do you crave the drug? If so, when you crave the drug, can you talk yourself into using it, even when you had resolved to not use? When you have resolved not to use, do you find yourself using under known craving conditions: environment, withdrawal (bored, irritable, sleep disordered), anxiety or blue, or when you are stressed?

Are You an Addict? : 

Are You an Addict? 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.

Are You an Addict? : 

Are You an Addict? 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?

What to do : 

What 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.

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. Definition of Addiction

C I M Model TreatmentCraving Identification and Management : 

C I M Model TreatmentCraving Identification and Management 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

C I M Model Treatment Causes of Craving : 

C I M Model Treatment Causes of Craving 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

C I M Model TreatmentComponents of Treatment : 

C I M Model TreatmentComponents of Treatment Initiation of Abstinence: Stopping Use Drug Detoxification: Use of medications to control withdrawal symptoms Avoidance Strategies: Measures to protect the client from environmental cues Schedule: Establishing times for arising, mealtimes, and going to bed Mental Health Assessment and Treatment Relapse Prevention Drug Detoxification: Continued use of medications to control withdrawal Avoidance Strategies: Controlled re-entry to cue-rich environments Schedule: Adherence to a regular daily lifestyle HUNGRY Three regularly spaced meals each day ANGRY Separate feelings of anger from losing control of behavior LONELY One positive social contact per day minimum TIRED Daily practice of sleep hygiene Tools: Behaviors that dissipate craving Exercise Spiritual Practice Talk Peer Support Groups Counseling Having Fun Mental Health Treatment

TOBACCO CESSATION: Initiating Abstinence : 

TOBACCO CESSATION: Initiating Abstinence Establish therapeutic alliance Assess biopsychosocial model Risk factors Circumstances of initial use Use History and prior quit attempts Assess four causes of craving Environment: Other smokers in (home, work, school) Paraphernalia in environment Mental Health treatment plan Withdrawal management plan Stresses associated with smoking 4. Set Quit Date

TOBACCO CESSATION: Relapse Prevention : 

TOBACCO CESSATION: Relapse Prevention Monitor use, craving scores, adherence to plan Modify plan to address weaknesses Continue modified plan, assess craving scores and craving causes Monthly telephone follow up calls

C I M Model TreatmentDetoxification : 

C I M Model TreatmentDetoxification Use of medications to treat withdrawal symptoms.

Continuous abstinence with varenicline, bupropion, placebo : 

Continuous abstinence with varenicline, bupropion, placebo

C I M Model TreatmentAvoidance Strategies : 

C I M Model TreatmentAvoidance Strategies Measures to Protect the Client From Exposure to Environmental Cues Identification of environmental cues Development of avoidance strategies-specific plan to avoid each cue Rehearsal of avoidance strategies Implementation of avoidance strategies changing phone numbers seeking safe housing avoiding old using haunts separating from old using partners/situations plans for handling money Enforced isolation-strict avoidance of conditioned cues and total isolation from the using environment during the first four to six weeks of recovery.

C I M Model TreatmentRecovery Tools : 

C I M Model TreatmentRecovery Tools Behaviors that dissipate craving Exercise: Two 20 minute exercise periods daily Spiritual practices: Meditation Prayer Talk Treatment groups Journal writing Peer support groups Narcotics Anonymous Individual counseling Alcoholics Anonymous Counseling Cognitive Behavioral Therapy (CBT) Motivational Enhancement Therapy (MET) Contingency Contracting Baths/Showers: hot or cold Orgasm: safe sex/self sex Relaxation exercises: using audio tapes or learned behavioral techniques Having Fun

C I M Model TreatmentRelapse Prevention : 

C I M Model TreatmentRelapse Prevention Principles Addicted persons relapse because of craving. Craving has causes that can be predicted, recognized and analyzed. Craving can be managed with the use of program activities. Questions about Craving What is your craving score? What is the cause of your craving? Environmental cue Stress Drug withdrawal Mental health problems What will you do to take care of yourself? Avoidance strategies Stress Management Tools Program activities

RECOVERY COACHING : 

RECOVERY COACHING How is it going; are you able to not smoke? What are your craving scores, now and highest in the last day What cause of craving is the worst? (people smoking around them, persistent withdrawal, depression/anxiety/dysphoria, stressed What are you going to do to take care of yourself? Exercise Change medications Use tools

Treatment works! : 

Treatment works! Tobacco dependence is a chronic condition requiring repeated intervention. Every client who uses tobacco should be offered treatment. Brief treatment for tobacco dependence is effective. Strong dose-response relationship between intensity of counseling (minutes of contact) and effectiveness: Pharmacotherapy is effective. All clients should be offered medications to help them quit smoking. Identifying and treating co-morbid conditions improves outcomes (anxiety, depression, PTSD, ADHD,SUD). Treatment for tobacco dependence is clinically effective and cost- effective.

Prevention : 

Prevention Reduce prenatal nicotine exposure Reduce prenatal alcohol and drug exposure Identify high risk groups for early intervention family history of addiction prenatal nicotine/alcohol/drug exposure perinatal asphyxia, poor cognitive development Identify and treat ADHD Identify and treat co-morbid mental health disorders, e.g., depression, anxiety, PTSD, thought disorders

REFERENCES : 

REFERENCES Benowitz N. Neurobiology of nicotine addiction: implications for smoking cessation treatment. American Journal of Medicine. 121(4A) S3-S10 (2008). 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. 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.