1. Orientation to addiction medicine and recovery Disclosure and Sponsorship Orientation to addiction medicine and recovery Disclosure and Sponsorship Willingway Hospital Quietly saving lives 311 Jones Mill Road Statesboro, GA 30458 800 242 9455 Willingway.com 1

2. Addiction Medicine: Orientation to the Science of Addiction or An experienced addictionist reflects on applying science to service October 23, 2010 4th Annual Addiction & Compulsive Behaviors Symposium Paducah, KY Al J. Mooney MD Medical Director, The Healing Place of Wake County Chairman, Willingway Foundation Associate Clinical Professor of Family Medicine, UNC Chapel Hill

3. Discussion point #1Discussion point #1 Solving Americas #1health problem Solving Americas #1health problem Alcoholism and drug dependency conditions are major contributors to morbidity and mortality in mental health and physical health environments Alcoholism and drug dependency conditions are major contributors to morbidity and mortality in mental health and physical health environments

4. Discussion point #2Discussion point #2 If a tree falls in the woods and nobody is there, does it make a noise? 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 Knowledge of recent addiction science and neuroscience strengthens our understanding of addictive illness and recovery

5. Discussion point #3Discussion point #3 Thats an ugly mole. Lets take it off so you dont get melanoma Thats an ugly mole. Lets take it off so you dont get melanoma A person who has consumed 5 drinks or more (4 for women) on any day in the past year is a risky drinker A person who has consumed 5 drinks or more (4 for women) on any day in the past year is a risky drinker

6. Discussion point #4Discussion point #4 Walk a mile in my shoes 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 Peer and mutual support (AA, NA, 12 step work, and mutual support) are promising to be effective bridges to life-long addiction recovery

7. Discussion point #5Discussion point #5 S*** happens 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 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

8. 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

9. Where science meets the sickness What evidence is there that the alcohol and drug problem is the number one health problem in America?

10. Disease facts – The problem Fatal illness Fatal illness 100,000 deaths annually 100,000 deaths annually YPLL = Cancer + Heart Disease YPLL = Cancer + Heart Disease >80% unanticipated deaths in community mental health >80% unanticipated deaths in community mental health Number 1 Health problem Number 1 Health problem $466 billion annual cost of NOT treating $466 billion annual cost of NOT treating No claims data to use for policy formulation No claims data to use for policy formulation 7% U.S. population afflicted 7% U.S. population afflicted ¼ of hospital admissions ¼ of hospital admissions Family morbidity 43% (76,000,000) Family morbidity 43% (76,000,000) 100% increase in healthcare costs 100% increase in healthcare costs Primary cause of preventable birth defects Primary cause of preventable birth defects Treatment yield of $7 for $1 expense Treatment yield of $7 for $1 expense $39 Yield for each $1 spent in medical settings $39 Yield for each $1 spent in medical settings Prevention reduces risk by 75% Prevention reduces risk by 75%

11. How to be blinded by the evidence Scientific methods are being used in ways that corrupt measurement of meaningful outcomes Scientific methods are being used in ways that corrupt measurement of meaningful outcomes Adjust length of study to misrepresent outcome Adjust length of study to misrepresent outcome Measure effects that justify use of medication Measure effects that justify use of medication Avoid measurement of side effects Avoid measurement of side effects Emphasize statistical endpoints not relevant to clinical efficacy Emphasize statistical endpoints not relevant to clinical efficacy Pay researchers to publish positive outcomes Pay researchers to publish positive outcomes Dont report negative results Dont report negative results Publish research ghostwritten by marketing staff under physician bylines Publish research ghostwritten by marketing staff under physician bylines Avoid comparison with alternatives known to be effective Avoid comparison with alternatives known to be effective 11

13. Suicide (1950-2005) Sources: Centers for Disease Control and Prevention, National Center for Health Statistics. From Health, United States, 2005

14. Suicide by age (1990-2005)

17. Infection Death Rates

19. Settlements for illegal or unethical drug marketing practices Astra Zeneca$520,000,000 Astra Zeneca$520,000,000 http://www.astrazeneca-us.com/about-astrazeneca-us/newsroom/8936389?itemId=8936389 http://www.astrazeneca-us.com/about-astrazeneca-us/newsroom/8936389?itemId=8936389 Pfizer $2,300,000,000 Pfizer $2,300,000,000 http://www.ama-assn.org/amednews/2009/09/14/prl20914.htm http://www.ama-assn.org/amednews/2009/09/14/prl20914.htm Purdue Pharma$634,500,000 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 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 Lilly$1.400,000,000 http://www.bmj.com/content/338/7688/News.full.pdf http://www.bmj.com/content/338/7688/News.full.pdf http://www.taf.org/top20.htm

20. Disease facts – The problem Fatal illness Fatal illness 100,000 deaths annually 100,000 deaths annually YPLL = Cancer + Heart Disease YPLL = Cancer + Heart Disease >80% unanticipated deaths in community mental health >80% unanticipated deaths in community mental health Number 1 Health problem Number 1 Health problem $466 billion annual cost of NOT treating $466 billion annual cost of NOT treating No claims data to use for policy formulation No claims data to use for policy formulation 7% U.S. population afflicted 7% U.S. population afflicted ¼ of hospital admissions ¼ of hospital admissions Family morbidity 43% (76,000,000) Family morbidity 43% (76,000,000) 100% increase in healthcare costs 100% increase in healthcare costs Primary cause of preventable birth defects Primary cause of preventable birth defects Treatment yield of $7 for $1 expense Treatment yield of $7 for $1 expense $39 Yield for each $1 spent in medical settings $39 Yield for each $1 spent in medical settings Prevention reduces risk by 75% Prevention reduces risk by 75%

21. Drug types Alter a disease Alter our perception of reality

22. Example: Benadryl Help allergy symptoms

23. Example: Benadryl Help allergy symptoms Sedation or antianxiety = relapse risk

24. Example: Morphine Assist heart pumping Euphoria or high = relapse risk

25. Alcohol effect on brain < 0.05% Prefrontal Cortex disinhibition > 0.05% Amgdyla emotional >0.20% RAS hypnosis >0.30% Medulla - Respiratory depression and death >0.10% Cerebellum – ataxia

26. Drugs of abuse Stimulants Narcotics Sedatives Other

27. Drugs of abuse Alcohol Heroin Crack Paxil Morphine Benadryl Marijuana PCP LSD Crystal Meth Special K T Valium Ativan Xanax Codiene Butalbital Ambien Ultram Adderal Ritalin Chloral Hydrate Peyote Glue Buprenorphine Methadone Dextromethoraphan Restoril Soma Methaqualone Klonopin Zoloft Prozac Ice

28. Tolerance and dependence CNS Activity Time

29. Tolerance and dependence CNS Activity Time

30. Tolerance and dependence CNS Activity Time

31. Tolerance and dependence vs. addiction CNS Activity Time

32. Addictive cycle 1. Physical Allergy 2. Mental Obsession

33. Natural rewards survival urges (nutrients) Air Air Food Food Water Water Sex Sex Intimacy (connectedness) Intimacy (connectedness)

34. Addiction Brain

35. Addiction Cascade Drink Drunk Abstain Trouble Switch Chemical or beverage Urge to use Use again

36. Addiction Cascade Drink Drunk Abstain Trouble Switch Chemical or beverage Urge to use Use again Abandon values Self-deception (Denial)

37. Addiction is progressive Symptoms Onset Disability Diagnosable Death Severity Time

38. Addiction is progressive Symptoms Onset Disability Diagnosable Death Severity Time

39. Addiction is progressive Symptoms Onset Disability Diagnosable Death Severity Time

40. Addiction and health nationally: Brain science Neuroplasticity Neuroplasticity Survival function of brain Survival function of brain Brain mapping Brain mapping Executive function Executive function Abstinence Abstinence

42. Evidence based medicine Science behavior change Science behavior change MH/PC Integration MH/PC Integration SBIRT SBIRT Peer methodology Peer methodology

43. Identifying the problem Drinking in America

44. Motivational Readiness Precontemplation Contemplation Preparation Action Maintenance

45. Clinicians Guide – Helping People Who Drink Too Much Do you sometimes drink alcohol? Do you sometimes drink alcohol?

46. 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 46

47. Peer specialty developmentPeer specialty development Understand the mortality of public mental health Understand the mortality of public mental health Solicit capacity for Angel calls Solicit capacity for Angel calls Identify those at risk or with a desire to stop Identify those at risk or with a desire to stop MH/PC integration (SBIRT) MH/PC integration (SBIRT) Screening, triage, referral (STR) points Screening, triage, referral (STR) points Introduce the culture of recovery Introduce the culture of recovery Leadership development Leadership development Empowers tracer methodology for quality Empowers tracer methodology for quality

48. SBIRT methodology Step 1: Ask about alcohol use Step 1: Ask about alcohol use Step 2: Assess for alcohol use disorders Step 2: Assess for alcohol use disorders At-risk drinking At-risk drinking Alcohol use disorders Alcohol use disorders Step 3: Advise and assist Step 3: Advise and assist Step 4: Followup and continue support Step 4: Followup and continue support

49. History of Angel Calls 1935 – Mutual support recovery and 12 th step work 1935 – Mutual support recovery and 12 th step work 2001 – Department of Surgery U of L collaborates with The Healing Place 2001 – Department of Surgery U of L collaborates with The Healing Place 2004 – Rick Blondell investigates with inpatient clinical trial methodology 2004 – Rick Blondell investigates with inpatient clinical trial methodology 2006 – North Carolina replication of a similar community model in a public mental health system 2006 – North Carolina replication of a similar community model in a public mental health system 2008 – Other replications in NC and acute care 2008 – Other replications in NC and acute care

51. Promote success in recovery by engaging and linking its phases: –Next, do something worthwhile with it –Finally, live as long as you can The Recovery Book –First, save your life

52. Recovery phases or zones Phase I. Salvage life Phase I. Salvage life Phase II. Make life worthwhile Phase II. Make life worthwhile Phase III. Prolong life Phase III. Prolong life Safety Zone Safety Zone Work Zone Work Zone Comfort Zone Comfort Zone

53. Zones in the recovery timeline Initial recoveryReconstruction Terminal illness Years

54. Summary Most recover with proper motivation and treatment Most recover with proper motivation and treatment Recovery happens in phases Recovery happens in phases Application of the principle of Zones will improve length and quality of recovery Application of the principle of Zones will improve length and quality of recovery

55. THE RECOVERY BOOK Al J. Mooney MD 509 Midenhall Way Cary, NC 27513 Mobile: 919 238 9349 Email: amooney@aol.com