“Addiction: Then and Now”

“Addiction: Then and Now”
Michael M. Miller, MD Plenary Session Wisconsin Psychological Association 2015 Annual Meeting Middleton, Wisconsin April 17, 2015Wisconsin Psychological Association April 17, 2015

Michael M. Miller, MD, FASAM, FAPA mmiller@rogershospital.org
Medical Director Herrington Recovery Center Rogers Memorial Hospital Oconomowoc, Wisconsin Clinical Adjunct Professor University of Wisconsin School of Medicine and Public Health Assistant Clinical Professor Medical College of Wisconsin, Department of Psychiatry and Behavioral Health Past President American Society of Addiction Medicine (ASAM) Director American Board of Addiction Medicine (ABAM) and The ABAM Foundation Fellow ASAM and American Psychiatric Assoc. Member Council on Medical Quality and Population Health, Wisconsin Medical Society Council on Science and Public Health, American Medical Association

“Addiction: Then and Now”
The Past President of the American Society of Addiction Medicine will draw from his presentation on the History of Addiction Treatment given to the ASAM Review Course in Addiction Medicine to review how alcoholism and addiction have been conceptualized and addressed in America over the past 125 years and how the ASAM Definition of Addiction (adopted 2011) offers new insights into the biological nature of this bio-psycho-social-spiritual disease and how addiction can involve the pathological pursuit or reward or relieve via engagement in “addictive behaviors” such as gambling, sex, and internet gaming. Objectives: Attendees will be able to describe for their patients and their family members what happens in the brain in cases of addiction and what neuroscience has revealed about the neuroanatomy and neurochemistry of addiction. Attendees will be able to understand how previous conceptualizations of alcoholism contributed to stigma and therapeutic pessimism about this illness, especially among physicians, and the role of medical professional societies in changing beliefs and attitudes about addiction, treatment, and recovery. Attendees will gain a deeper understanding of how Alcoholics Anonymous has influenced professional treatment of addiction in the United States. Attendees will be able to advocate for expanded research regarding “behavioral addictions” based on their understanding of what is known and what is unknown about non-substance-related addiction.

Michael M. Miller, MD, FASAM, FAPA
History of Addiction Treatment in North America And the History of Addiction Medicine Michael M. Miller, MD, FASAM, FAPA Past President, ASAM The ASAM Review Course September 19, 2014 Orlando, Florida

Medical Director, Herrington Recovery Center Rogers Memorial Hospital, Oconomowoc, Wisconsin Clinical Adjunct Professor University of Wisconsin School of Medicine and Public Health Assistant Clinical Professor Medical College of Wisconsin Past President, American Society of Addiction Medicine At-Large Director, American Board of Addiction Medicine Former Delegate, AMA House of Delegates (ASAM) Former Chair, JCAHO HAP PTAC (ASAM) Delegate, AMA House of Delegates (Wisconsin) Member, AMA Council on Science and Public Health

Addiction Treatment in the U.S.
“The Minnesota Model” Hazelden Foundation Willmar State Hospital Miller MM. “Treatment of Addiction: A Clinical Overview." In Principles of Addiction Medicine, First Edition, (ASAM) Miller MM. “Traditional Approaches to the Treatment of Addiction." In Principles…, Second Edition, 1998. Addiction Treatment in the U.S. is often caricatured as nothing other than that

One Reference Everyone Cites
“Slaying the Dragon” The History of Addiction Treatment and Recovery in America William L. White Bloomington, IL: Chestnut Health Systems. 1998

Outline How do we conceptualize what we’re treating?
Early treatment approaches in America AA (but it is not treatment) Hazelden and the Minnesota Model Treatment Programs – East Coast, SE, Midwest Treatment Programs – West Coast, et al. General Musings about Addiction Treatment –so, what is Addiction Treatment anyway?

Outline History of Addiction Treatment Research
History of Addiction Policy and Advocacy History of Addiction Medicine Broadening the Base of Treatment Pharmacotherapy Treatment Criteria Chronic Disease Management Contemporary Addiction Treatment Living History as it Happens

Addiction How the Condition is Conceptualized
The signatory of the U.S. Declaration of Independence, Dr. Benjamin Rush, had described the “alcoholic disease syndrome” in 1779 (Li, Hewitt, Grant, 2007). The two terms most frequently used to refer to alcoholism at the end of the nineteenth century were dipsomania and inebriety (White, 2004), with both referring to the behaviors of excessive drinking and intoxication.

The Journal of Inebriety
Weiner, B., & White, W. The Journal of Inebriety (1876–1914): history, topical analysis, and photographic images. Addiction, 102 (1): 15-23, 2007 .

Addiction: How the Condition is Conceptualized
Alcoholism is one thing Drug Addiction is another

Addiction How the Condition is Conceptualized
The term “addiction to alcohol” appears to have first been used in the German medical literature in 1901 (Bonhoeffer, 1901; Blakemore, Jennett, 2001), but it became established enough that the National Conference on Nomenclature of Disease, the 1933 American process that had inspired the International Classification of Disease (the latest edition, from 1992, is ICD-9), had a diagnostic code for "alcohol addiction (code )” (Keller, 1976). Jellinek himself (Jellinek, 1942) referred to “alcohol addiction” (Robinson, 1972) for almost two decades prior to the publication of his best known work, The Disease Concept of Alcoholism (Jellinek, 1960). He also described phases of alcohol addiction in an attempt to capture the heterogeneity in manifestations of the disease (Jellinek, 1952).

The Broader Context The American Medical Society on Alcoholism and Other Drug Dependencies Alcohol vs. Drugs Alcoholics Anonymous Narcotics Anonymous Alcohol, Nicotine, and Other Drugs

WHO Expert Committee on Mental Health, Alcoholism Subcommittee (1st Report, 1950)
“Alcoholism: any form of drinking which in its extent goes beyond the traditional and customary ‘dietary’ use, or the ordinary compliance with the social drinking customs of the whole community concerned, irrespective of the etiological factors leading to such behavior….” WHO Technical Report Series No. 42, December 1950, pg 5

WHO Expert Committee on Mental Health, Alcoholism Subcommittee (2nd Report, 1952)
“The subcommittee has distinguished two categories of alcoholics, ‘alcohol addicts’ and ‘habitual symptomatic excessive drinkers’. For brevity’s sake the latter will be referred to as non-addictive alcoholics. In both groups, the excessive drinking is symptomatic of underlying psychological or social pathology….” WHO Technical Report Series No. 48, August 1952, pp

“The subcommittee would now consider it more appropriate to use the preceding definition to define the term ‘excessive drinking’ and would add to it the following definition of alcoholism:” WHO Technical Report Series No. 48, August 1952, pg 16

“…but in one group after several years of excessive drinking ‘loss of control’ over the alcohol intake occurs, while in the other group this phenomenon never develops. The group with ‘loss of control’ is designated as ‘alcohol addicts’.” WHO Technical Report Series No. 48, August 1952, pp 26-27

WHO Expert Committee on Drugs Liable to Produce Addiction
“Drug addiction is a state of periodic or chronic intoxication, detrimental to the individual and to society, produced by the repeated consumption of a drug (natural or synthetic). Its character-istics include: an overpowering desire or need (compulsion) to continue taking the drug and to obtain it by any means

WHO Expert Committee on Drugs Liable to Produce Addiction
“(2) a tendency to increase the dose; (3) a psychic (psychological) and sometimes a physical dependence on the effects of the drug.” WHO Technical Report Series No. 21, 1950

WHO Expert Committee on Mental Health, Alcoholism Subcommittee (1st Report, 1950)
“…the Subcommittee recommends that consideration should be given to the setting-up of a subcommittee on Alcohol of the Expert Committee on Drugs Liable to Produce Addiction.” WHO Technical Report Series No. 42, December 1950, pg 6

The Definition of Alcoholism (NCADD / ASAM – 1990, JAMA 1992: Morse et al.)
Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic: impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.

What is Addiction? American Society of Addiction Medicine • April 2011
Definition of Addiction: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

Definition of Addiction American Society of Addiction Medicine • April 2011
“Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

Models for Understanding Addiction Joseph Westermeyer, MD, PhD, MPH
Moral Model, Criminal Model, Epidemic Model, Illness Model, Personality Disorder Model, Learning Model, Self-treatment Model, Genetic Model, et al. “This model evolved over two centuries ago when addicted persons were unable to cease addictive use of psychoactive substances on their own.” Westermeyer J. “Chapter 1: Historical Understandings of Addiction.” In: Principles of Addiction (Peter M. Miller, ed.). Elsevier (2013), page 4.

“First, the addicted person must view him- or her-self as a blighted or diseased person in need of outside help. This step, involving illness behavior, occurs after a period of misery and dysfunction. Second, those around the person must be willing to deed the person a period of relief from ordinary social expectations and responsibilities, in order to permit treatment and recovery. This involved social assignment of a temporary sick role. Third, a culturally approved or licensed health care worker must ordain that disease exists and treatment is warranted.” Westermeyer J. “Chapter 1: Historical Understandings of Addiction.” In: Principles of Addiction (Peter M. Miller, ed.). Elsevier (2013), page 4.

Responses to Addiction
The Washingtonians – The Washingtonian Total Abstinence Society “The Washingtonian program of recovery consisted of (1) public confession, (2) public commitment, (3) visits from older members, (4) economic assistance, (5) continued participation in experience sharing, (6) acts of service toward other alcoholics, and (7) sober entertainment.” White, 1998, page 10.

Antediluvian Addiction Care (before the Minnesota Model)
The Moral Movement and Dorothea Dix From Wikipedia: Moral treatment was an approach to mental disorder based on humane psychosocial care or moral discipline that emerged in the 18th century and came to the fore for much of the 19th century, deriving partly from psychiatry or psychology and partly from religious or moral concerns. The movement is particularly associated with reform and development of the asylum system in Western Europe at that time. It fell into decline as a distinct method by the 20th century, however, due to overcrowding and misuse of asylums and the predominance of biomedical methods.

The Earliest Institutions
“During the second half of the 19th century, there was a rapid growth in the number of institutions specializing in the treatment of inebriety. When a professional association of inebriate home and inebriate asylum managers – the American Association for the Cure of Inebriates – was launched in 1870, only six institutions were in operation. By 1878, 32 institutions were represented in the association, and by 1902 there were more than 100 facilities in the U.S. that specialized in the treatment of alcoholism and other addictions. White, W. (1998). “Chapter 4. The Rise and Fall of Inebriate Homes and Asylums.” Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut Health Systems.

Inebriety “If one central idea was shared across the spectrum of early treatment programs, it was the concept of ‘inebriety.’ ‘Inebriety’ encompassed a wide spectrum of disorders that resulted from acute or chronic consumptions of psychoactive drugs. ‘Inebriety’ was the term that captured the morbid craving, the compulsive drug-seeking, and the untoward physical, psychological and social consequences of drug use.” White, W. (1998).] “Chapter 5. Inebriate Homes and Asylums: Treatment Philosophies, Methods and Outcomes.” Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut Health Systems.

Treatment Philosophies
Inebriety was broken down into its numerous forms through elaborate classification systems that included “alcohol inebriety,” “opium inebriety,” “cocaine inebriety,” “tobaccoism,” “chloroform inebriety….” White, W. (1998). “Chapter 5. Inebriate Homes and Asylums: Treatment Philosophies, Methods and Outcomes.” Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut Health Systems.

Pre-Asylum Days: Care of the Addicted
“Before the development of institutions specializing in the treatment of addiction, alcoholics and addicts landed in all manner of institutions – the almshouse, the charitable lodging home, the jail, the workhouse, and the newly created asylum. None of these institutions desired the inebriate’s presence, and none were equipped to treat addiction.” White, W. (1998). “Chapter 4. The Rise and Fall of Inebriate Homes and Asylums.” Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut Health Systems.

A Variety of Modalities
Hydrotherapies Drug Therapies The Keeley Institutes, Dr. Leslie Keeley: the Double Chloride of Gold Morphine for Alcoholism Tonics and Elixirs of the Patent Drug Era Convulsive Therapies – 1930’s Psychosurgery – 1940’s

Reforms in 1906 Flexner Report Pure Food and Drug Act
“…The Pure Food and Drug Act contained some of the earliest federal provisions affecting narcotics; if any over-the-counter remedy in interstate commerce contained an opiate, cannabis, cocaine, or chloral hydrate, the label was required to state its contents and percentage. The effect of this simple measure apparently was to reduce the amount of such drugs in popular remedies and also to hurt their sales, although other proprietaries flourished.” Musto DF. Chapter 1: Historical Perspectives. In: Lowinson, J. , editor (2005). Substance Abuse: A Comprehensive Textbook (Fourth Edition). Philadelphia: Lippincott Williams & Wilkins, page 4.

“During the early 1900’s, diagnostic classifications included alcoholism and drug addictions as personality or character disorder. These disorders were viewed as a form of antisocial personality, since the individual broke social mores, acted primarily in their own apparent self-interest, and often transgressed the rights of others while intoxicated or drug seeking According to this view, addiction evolved in irresponsible or self-centered people who ignored the effects of their choices and behaviors on others. The 2nd Edition of the DSM of the APA typified this perspective.” Westermeyer J. “Chapter 1: Historical Understandings of Addiction.” In: Principles of Addiction (Peter M. Miller, ed.). Elsevier (2013), page 5.

“During this period personality and character disorder were seen as untreatable. Thus, this model justified the noninvolvement of many clinicians in the care of these patients. Abandoned by the medical profession, alcoholics in the United States supported one another’s recovery in the brotherhood of Alcoholics Anonymous.” Westermeyer J. “Chapter 1: Historical Understandings of Addiction.” In: Principles of Addiction (Peter M. Miller, ed.). Elsevier (2013), page 5.

A bit of history… From “Alcoholics Anonymous”, the “Big Book” of A.A.

Alcoholics Anonymous is an international fellowship of men and women who have had a drinking problem. It is nonprofessional, self-supporting, multiracial, apolitical, and available almost everywhere. There are no age or education requirements. Membership is open to anyone who wants to do something about his or her drinking problem.

Taking a step back Origins and Notables
Oxford Groups (a spiritual movement in the 1920’s in Pennsylvania—Frank Buchman) “The Central Idea of the Oxford Group was that the problems of the world could be healed through a movement of personal spiritual change.” (White, 1998, page 128) William Silkworth, MD—in 1930 became physician in charge at the Charles B. Towns Hospital for the Treatment of Drug and Alcohol Addiction in New York City (founded in 1901)

Charles B. Towns: “Towns’ writings on addiction described and brought to popular understanding the most essential elements of physical addiction: (1) increased tissue tolerance, (2) an identifiable withdrawal syndrome following cessation of drug use, and (3) craving and compulsive drug-seeking behavior.” Bill Wilson was admitted on December 1934. White, W. (1998).] “Chapter 10. Physical Methods of Treatment and Containment.” Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut Health Systems.

William Silkworth, MD. “He described alcoholism as an allergy of the body and an obsession of the mind.” “Silkworth’s suggestion of a constitutional vulnerability which prompted alcoholics to drink—out of necessity rather than choice—became the cornerstone of the modern disease concept of alcoholism.” White, W. (1998).] “Chapter 15. The Birth of Alcoholics Anonymous: A Brief History.” Slaying the Dragon: The History of Addiction Treatment and Recovery in America. Bloomington, IL: Chestnut Health Systems.

Akron, Ohio St. Thomas Hospital “Managed Care and its Impact on Addiction Treatment” 8th Annual St. Thomas Hospital Conference on Addictions: Issues In Addiction Treatment In A Changing Healthcare Environment Summa Health System, Akron, Ohio, October 9, 1996 Sister Ignatia Dr. Bob Smith Bill Wilson

Bill Wilson was on a business trip to Akron, things weren’t going well with that, and he was concerned he would lose the sobriety that dated to December 1934, so he looked for an Oxford Group member to call; his phone calls led to his being connected with Dr. Bob and they met in a woman’s home on May 12, [ Note: They did not meet at the hospital; Dr. Bob was never Bill W’s doctor. ]

Their meeting resulted in Bill W. staying sober and Dr. Bob getting sober…until he went to the AMA annual meeting in Atlantic City in June, where he got drunk and “missed most of the conference.” Back in Akron, Bill W. gave Dr. Bob his last drink, “two bottles of beer in the morning on June 10th, 1935, to settle his shaking hands before he went in to the hospital to perform surgery. This date represents the official start of” A.A.—two alcoholics helping each other. [Thanks to William Highberger, MD]

Since the book Alcoholics Anonymous first appeared in 1939, this basic text has helped millions of men and women recover from alcoholism.

Foreword to First Edition
PRECISELY HOW WE HAVE RECOVERED Better understand the alcoholic The alcoholic is a very sick person Anonymity Non alliance

Foreword to the Second Edition
By 1955 6000 groups, 150,000 members The two elements of recovery Carry the message – alcoholic to alcoholic Spiritual principles A brief history of the early days

Foreword to the Third Edition
By over 1,000,000 members and 28,000 groups “…At its core it remains simple and personal. …One alcoholic talks to another alcoholic sharing experience strength and hope.”

As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery. ‡

Public Policy Statement on the Relationship Between Treatment and Self Help: A Joint Statement of the American Society of Addiction Medicine, Inc., the American Academy of Addiction Psychiatry, and the American Psychiatric Association

Public Policy Statement (1997) on the Relationship between Treatment and Self Help: a Joint Statement of the American Society of Addiction Medicine, the American Academy of Addiction Psychiatry, and the American Psychiatric Association ASAM, AAAP and APA recommend that: 1. Patients in need of treatment for alcohol or other drug-related disorders should be treated by qualified professionals in a manner consonant with professionally accepted practice guidelines and patient placement criteria; 2. Self help groups should be recognized as valuable community resources for many patients in addiction treatment and their families. Addiction treatment professionals and programs should develop cooperative relationships with self help groups; 3. Insurers, managed care organizations and others should be aware of the difference between self help fellowships and treatment; 4. Self help should not be substituted for professional treatment, but should be considered a compliment to treatment directed by professionals. Professional treatment should not be denied to patients or families in need of care.

Recovery from addiction is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.

Addiction Treatment The Minnesota Model
Build upon the principles of Alcoholics Anonymous Utilizing the multi-professional team as is used in inpatient psychiatric treatment The mentally ill stayed for a lifetime Treatment for the alcoholic: some could leave in a year Duration: 6 months, 3 months, 2 months….

Willmar Treatment of the Chronically Mentally Ill
Psychiatrists (MD/DO) General Medical Physicians Psychologists Nurses Social Workers Occupational Therapists Recreation Therapists Art and Music Therapy Nutrition: Registered Dieticians

Daniel J. Anderson, Ph.D. Master of Arts in clinical psychology, Loyola University in Chicago, 1956 Ph.D. in clinical psychology, University of Ottawa, 1966. Clinical psychologist at Willmar State Hospital from 1952 to 1961. Consultant and lecturer, Hazelden, He joined Hazelden full time in 1961 and was executive vice president and director there until 1971. President of Hazelden, 1971 until 1986.

Daniel J. Anderson, Ph.D. As a psychologist at Willmar State Hospital in the 1950s, Anderson and Nelson Bradley, superintendent of the hospital, were dedicated to finding an effective way to address "inebriates," a group that was considered "at the bottom of the patient pecking order" at that time, Anderson said in a 1998 interview. "Everyone looked down on them, including the community, hospital staff, and even our mentally ill patients. The inebriates had a lower status than the schizophrenics and the manic depressives, or even the kleptomaniacs or pedophiles."

Hazelden Bio-Psycho-Social-Spiritual Illness
Bio-Psycho-Social-Spiritual Treatment Multidisciplinary Team Principles of AA Family Recovery Group Therapy is Primary Individual Therapy is Supplement Multiple Family Groups > Individual Family Tx

From www.Hazelden.org Hazelden history
1947 The idea for Hazelden is born when Austin Ripley, a recovering alcoholic, sets out to create a rehabilitation center for alcoholic priests. Lynn Carroll, a lawyer and recovering alcoholic, and Robert McGarvey, owner of McGarvey Coffee, support Ripley's pursuit but favor a center that would serve "all professionals." Ripley's insistence on a priests-only facility removes him from the venture. 1948 Carroll initiates a meeting that paves the way for Hazelden. Joining Carroll and McGarvey, are Richard Coyle Lilly, a St. Paul banker, and other businessmen. On December 29, 1948, the Coyle Foundation authorizes purchase of the Power family farm in Center City, Minn., known as Hazelden Farms.

From 1949 Hazelden incorporates and admits its first patient: "the new hospital corporation is to operate the premises as a sanatorium for curable alcoholics of the professional class.“ Lawrence Butler is Hazelden's first patient. 1951 Emmett, Patrick and Lawrence Butler assume contract for deed of the financially troubled Hazelden. 1952 Patrick Butler is named president of Hazelden. The Butlers provide financial stability for Hazelden. 1953 Fellowship Club, a halfway house for men, opens in St. Paul. 1954 Pat Butler acquires rights to Twenty-Four Hours a Day, a meditation book for alcoholics, launching the beginning of Hazelden's publishing efforts.

ANDERSON, D. J. ; MCGOVERN, J. P. ; AND DUPONT, R. L
ANDERSON, D.J.; MCGOVERN, J.P.; AND DUPONT, R.L. The origins of the Minnesota Model of addiction treatment: A first person account. Journal of Addictive Diseases 18:107–114, 1999.

The other “pillar” in Minnesota
St. Mary’s Hospital, Minneapolis In-patient Hospital-based program started in 1968. Dr. George Mann, Medical Director, worked with Sr. Mary Madonna, president of St. Mary’s Hospital, to open the program over the objections of Board members who didn’t want “alcoholics” in the hospital. 4 weeks: third week was “family week” where family came and participated in a group, joined by the person “in treatment,” for 5 straight days. So for Week 3, the person joined multiple family group therapy with others who were in Week 3.

The Diaspora from Hazelden
To Lutheran General Hospital, Park Ridge, IL To Madison General Hospital (now: Meriter) To Proctor Hospital, Peoria, IL (Illinois Institute for Addiction Recovery, 1979) To hospitals too numerous to count To the Betty Ford Center (1982) …and now: the Hazelden Betty Ford Foundation

American Treatment Programs East Coast
Beech Hill Farm/Beech Hill Hospital (Dublin, NH)—John Supple ( ) Chit Chat Farms (Reading, PA)—now Caron (1959) Roosevelt Hospital: the Smithers Center (NYC) 1973 East Side; 1995 West Side Serenity Hill (New Canaan, CT)—James O’Neill (1974), the first detox/rehab in CT, JCAHO; sold to Parkside 1982; now Mountainside Seminole Point (Sunapee, NH)—James O’Neill ( ) Arms Acres (1982)/Conifer Park (1983) —New York

Before Almost All Others
The University of Buffalo Medical School established a Rehabilitation Center for alcoholics near the end of This was located in the Chronic Disease Institute under the auspices of the National Institute of Mental Health and the New York State Health Department, in conjunction with the University of Buffalo, as a tripartite arrangement. Block, Marvin A. American Journal of Public Health, August 1959: Vol. 49, No. 8, pp

American Treatment Programs East Coast
Boston State Hospital (closed 1979)—early provider of methadone services Edgehill Newport (Newport, RI) – treated Kitty Dukakis; closed. McLean Hospital/Harvard (Belmont, MA) Father Martin’s Ashley (Havre de Grace, MD) – 1983 Hanley Center (West Palm Beach, FL) – 1986 Talbott, Ridgeway, MARR, and Willingway (Ga) Thanks to Michael Walsh, NAATP, for reminiscences

Parkside Health Services (part of Lutheran General Hospital, Park Ridge, IL—now Advocate Health)
Flagship: Parkside (Lutheran General Hospital) Martin Doot, MD Over 100 locations, including the U.K. Treatment Criteria: David Mee-Lee, MD, Marblehead, MA Outcome Studies: Bill Filstead, PhD (in sociology and program evaluation) – later at the AMA

The US Navy Long considered the premier armed service for the treatment of addiction in active duty servicemen/women. In 1982, it was the Navy that filmed Father Martin’s “Chalk Talk” for use in its treatment programs

Long Beach Naval Station
70 acres at the north end of El Dorado Park in the City of Long Beach was sold to the U.S. Navy for $1 in 1965 to build a new naval hospital. It became known for its alcoholism treatment program which launched in 1967 and became known as the hub of the military's dependency program.[3] Perhaps its most famous patient was Betty Ford, who was admitted for drug and alcohol dependence in 1978.[ This hospital closed in 1994 along with the closing of the Long Beach Naval Shipyard and Naval Station and disbanding of the Long Beach Naval Fleet.

L.A. Times, November 2, 1997, DOUGLAS P. SHUIT, STAFF WRITER
Back in 1965, newly recovering alcoholic and retired Navy Cmdr. Dick Jewell wanted to know why the Navy wasn't doing more about alcoholism. He took his questions to Dr. Joseph J. Zuska, then the senior medical officer at the Long Beach Naval Station on Terminal Island. Treatment in Long Beach revolved around inpatient medical care, daily group therapy, psychological counseling, lectures and movies on alcoholism and--as a consequence of that first meeting between Jewell and Zuska--daily attendance at Alcoholics Anonymous meetings. "I made people go to a meeting every night," said Dr. Joseph A. Pursch, who succeeded Zuska as the program's director in "We had a meeting every Thursday night in the hospital. We had men and women from the outside come in." On other nights, Pursch said, Navy vans took patients to AA meetings in Long Beach, Signal Hill and other cities.

West Coast Programs Schick Shadel (1935)
Max Schneider MD at Orange County (1964) Viki (Vernell) Fox MD at Long Beach General (1971) Lyman Boynton MD at Kaiser—San Francisco Ron Mineo MD at Scripps Memorial—La Jolla Tony Radcliffe MD at Kaiser—So Cal (1978) Betty Ford Center (1982) Sierra Tucson (1983) Cottonwood de Tucson (1987) CRC Health (1995)—145 locations. 30,000 lives per day under treatment (some MH)

Betty Ford Center At Eisenhower Medical Center, Rancho Mirage, CA
The Center was co-founded by U.S. First Lady Betty Ford, Ambassador Leonard Firestone, and Dr. James West in West also served as the Betty Ford Center's first medical director, from 1982 until The administrator was an Illinois native, recommended by Hazelden from among its best administrative staff: John Schwarzlose (Proctor Hospital, Peoria; staff/administrators were trained by Hazelden). On February 10, 2014, Betty Ford Center merged with Hazelden Foundation to create the Hazelden Betty Ford Foundation. On June 12, 2014, Jim Steinhagen was named Vice President and Administrator in charge of the Betty Ford Center, and Steve Eickelberg, M.D., was appointed Medical Director of the Center.

West Coast – “Different Strokes”
Narcotics Anonymous (1953) – Los Angeles Synanon (1958) – Santa Monica Esalen Institute (1962) – Big Sur Haight Ashbury Free Clinic, Inc. – HAFCI – 1967 David Smith, MD Therapeutic Communities (not just West Coast) Later: Celebrity Rehab and Spas

TC’s Therapeutic Communities (TCs) are structured, psychologically informed environments – they are places where the social relationships, structure of the day and different activities together are all deliberately designed to help people’s health and well-being. ( DayTop Village (1964) – TC but also outpatient Phoenix House (1972) – > 120 programs in eleven states United Kingdom

Schick Shadel Hospital’s founder, Charles A. Shadel, was a pioneer in the field of treating alcoholism. He developed the counter conditioning treatment program for substance abuse, and, in 1935, opened up a colonial mansion with the comforts of home for those who were then considered society’s outcasts – alcoholics. Mr. Shadel believed that the only thing wrong with alcoholics was alcohol. His philosophy was that the body, not the mind, was dysfunctional. He viewed alcoholism as a drug addiction and, together with Dr. Walter Voegtlin, a Seattle gastroenterologist, developed and tested a safe and effective formula to create a chemical aversion to alcohol.

The work of Shadel Hospital in Seattle continued quietly and effectively until 1964, when then-chairman and CEO of the Schick Safety Razor Company, Patrick J. Frawley, Jr., checked into the facility. After the first day of the program, Frawley reported that he felt immediate relief from the compulsion to drink and, months later, was astonished to find that he still didn’t crave any of his favorite drinks.

Schick Safety Razor Company formed Schick Laboratories, Inc. with Frawley as chairman in 1965 and purchased the Shadel Hospital, investing $6 million in researching habit formation. The research, under the direction of Schick Shadel Hospital’s Chief of Staff, James W. Smith, M.D., resulted in a program for nicotine addiction. Programs for cocaine, marijuana, and methamphetamines, prescription opioids and heroin were later developed by the Schick Shadel clinicians. Today, Schick Shadel Hospital continues to treat patients using the evidence-based counter-conditioning techniques pioneered by Mr. Shadel.

Other large systems Charter HCA CRC Health
Of course, Hazelden-Betty Ford and Caron But none larger than the VA

“Professional Addiction Treatment” didn’t begin as professional treatment
Early treatment was started by and delivered by recovering alcoholics without any formal clinical training. These folks filled a void created by the abdication of the professional community to treat alcoholics. Almost all treatment staff were recovering alcoholics in AA and their treatment was “sharing their strength, hope and experience.” The major and non-negotiable requirement for counselor positions was two years of sobriety. Jerry Shulman, M.A. (ASAM Award 2012)

Musings of Shulman and Miller
Early treatment, which was based on an abstinence-based, Twelve Step, “disease concept” model, was not what would be considered treatment by today’s standards. There was no individualized assessment, no treatment planning and “treatment” was one size fits all. Group therapy was 10 patients sitting in a circle discussing a chapter in the book ”Alcoholics Anonymous.” But strangely, many of these early patients recovered and some went on to become alcoholism counselors. One explanation is that the patient group was very homogeneous with little co-occurring psychiatric problems. All alcoholics, almost all men, mostly middle-aged and employed, and psychiatric conditions and medications were not allowed.

One Level of Care: Inpatient
No IOP until 1970’s and 1980’s No “continuing care” – discharge planning from “rehab” was to “attend AA” rather than to see a professional “Aftercare” was a no-charge service. All services were self-pay.

Third Party Payment (Shulman)
In 1975, Blue Cross America, the trade organization for individual Blue Cross Plans, recommended that the individual plans develop an insurance benefit for alcoholism. Capitol Blue Cross (Southeast PA) sent a research analyst to live at Chit Chat Farms for a week to make recommendations for a plan. They were one of the first Blue Cross Plans to provide a benefit which was 30 days of inpatient treatment (no outpatient) and covered alcoholism but not drug addiction. The plan mirrored the provision of treatment at that time.

Third Party Payment (Shulman)
In Minnesota, the Blue Cross plan, collaborating with Hazelden, established a benefit which the Minnesota legislature mandated for all private insurance plans. With the advent of the impact of managed care in the late 1970s and the unwillingness of payers to reimburse for 28 day, fixed length of stay treatment, many inpatient programs which were unable to adapt, closed. Others developed more creative solutions including some which moved from a 28 day to a 21 day fixed length of stay but kept the overall charge for four weeks.

Recollections of Tony Radcliffe, MD ASAM President (1991-93)
General Medical Addictionist at Kaiser Permanente-Southern California The addiction benefit in the 1970s under Kaiser-SoCal was for alcohol addiction only, and only for members of the Federal Employees Health Benefit Program The comprehensive benefit for chemical dependency care in Kaiser was written as part of the basic medical benefit, not the psychiatric benefit (psychiatric benefits were supplemental benefits until the mid-1990s) Determination of whether to offer services to Kaiser Health Plan enrollees under this new benefit was based upon medical necessity, not the experience of previous episodes of detox care, etc. The establishment of medically-monitored detox within Kaiser-SoCal was made possible via a grant from the Kaiser Foundation The California legislation which enabled the establishment of the freestanding Betty Ford Clinic was used to enable Kaiser to establish a medically-managed inpatient service, under the Department of Medicine, in

A Response to Insurance’s “Intrusion”
The Northern Ohio Chemical Dependency Treatment Directors Association (NOCDTDA) create The Cleveland Criteria (Hoffmann, Halikas & Mee‑Lee, 1987) The NAATP Criteria (the National Association of Addiction Treatment Providers) are developed by Richard Weedman, 1988 The ASAM-NAATP Criteria ( ; Mee-Lee) The ASAM Criteria (1991; 1996; 2001)

What are we trying to accomplish through “Professional Treatment?”
ASAM Public Policy Statement on Treatment for Alcohol and Other Drug Addiction Addiction Treatment is the use of any planned, intentional intervention in the health, behavior, personal and/or family life of an individual suffering from alcoholism or from another drug addiction, and which is designed to enable the affected individual to achieve and maintain sobriety, physical, spiritual and mental health, and a maximum functional ability. Addiction Treatment services are professional healthcare services, offered to a person diagnosed with addiction, or to that person’s family, by an addiction professional. Addiction professionals providing addiction treatment services are licensed or certified to practice in their local jurisdiction and may be nationally certified by a professional certification body for their professional discipline. Adopted by ASAM Board of Directors May 1980; revised September 1986, October 1997, July 2001, October 2009, and January 2010.

Targeted Therapeutic Changes in Addiction Treatment
BEHAVIORAL CHANGES BIOLOGICAL CHANGES Eliminate alcohol and other drug use behaviors Eliminate other problematic behaviors Expand repertoire of healthy behaviors Develop alternative behaviors Identify triggers for using behaviors/relapses Resolve acute alcohol and other drug withdrawal symptoms Physically stabilize the organism Develop sense of personal responsibility for wellness Initiate health promotion activities (e.g., diet, exercise, safe sex, sober sex) Address cravings through medical interventions (treatment medications)

COGNITIVE CHANGES AFFECTIVE CHANGES Increase awareness of illness Increase awareness of negative consequences of use Increase awareness of addictive disease in self Decrease denial Increase emotional awareness of negative consequences of use Increase ability to tolerate feelings without defenses Manage anxiety and depression Manage shame and guilt

SOCIAL CHANGES SPIRITUAL CHANGES Increase personal responsibility in all areas of life Increase reliability and trustworthiness Become resocialized: reestablished sober social network Increase social coping skills: with spouse/partner, with colleagues, with neighbors, with strangers Increase self-love/esteem; decrease self-loathing Reestablish personal values Enhance connectedness Increase appreciation of transcendence Taken from: Miller, Michael M. Principles of Addiction Medicine, 1994; published by American Society of Addiction Medicine, Chevy Chase, MD

Treatment of Addiction
Screening, Brief Intervention, and Referral to Treatment (SBIRT) Individual or GROUP Counseling Family or Multifamily Group Therapy Pharmacotherapy Chronic Disease Management Comprehensive Case Management Consultation-Liaison Services

Components of Comprehensive ‘Drug Abuse’ Treatment
Child Care Services Family Services Vocational Services Intake Processing / Assessment Housing / Transportation Services Mental Health Services Behavioral Therapy and Counseling Substance Use Monitoring Treatment Plan Clinical and Case Management Self-Help / Peer Support Groups Pharmacotherapy Financial Services Medical Services Continuing Care Legal Services Educational Services AIDS / HIV Services 93

Treatment of Non-Substance Addiction
“Pathological Gambling” South Oaks Hospital – now North Shore-L.I. Jewish In January 1882, The Long Island Home Hotel for Nervous Invalids opened Amityville, New York Sheila Blume, MD S.O.G.S. But also: Proctor Hospital / I.I.A.R. (1993) and Paradigm Magazine (1995)

South Oaks Hospital In 1970, South Oaks established Hope House, a specialized inpatient unit for young men and women who were addicted to drugs. In 1971, recognizing the special needs of adolescents with emotional problems, the hospital opened an Adolescent Pavilion for young people between the ages of 13 and 20. In 1972, South Oaks set up a Training Program for Alcoholism Counseling. The training program, one of only a few in the country, graduated many trained counselors.

South Oaks Hospital In June 1980, South Oaks established Sage House, a rehabilitative program for young men aged 13 to 20 who had a history of abusing more than one drug, in combination with alcohol. In 1981, South Oaks conducted an extensive study and three-part program on compulsive gambling. With the advent of this program, South Oaks became one of the first hospitals in the country to offer services for compulsive gamblers and their families. A key feature of this program was South Oaks Gambling Screening (SOGS), a valuable tool for the detection of compulsive gambling problems.

History of Addiction Research (arguably, clinical research preceded basic research)
The Addiction Research Center, Lexington, KY—founded as the “Narcotic Farm” in 1935 Re-dedicated in 1948 as part of USPHS, conjointly administered by the federal Bureau of Prisons; there was also a prison hospital that did addiction research in Ft. Worth, TX (founded 1938) Mandatory minimum sentences for drug crimes; inmates “rewarded” with cocaine or opiates for participation in clinical trials Became part of NIDA in 1974 when that agency was established as part of the Alcoholism, Drug Abuse and Mental Health Administration (ADAMHA), the precursor to SAMHSA Relocated to Baltimore in 1979

NIDA Created in 1974 two years after the Drug Abuse Warning Network (DAWN) and National Household Survey on Drug Abuse (now the National Survey on Drug Use and Health) were initiated Predecessor had been the NIMH’s Division of Narcotic Addiction and Drug Abuse ONDCP was created in 1998 NIDA became part of NIH in 1992

In 1999, NIDA launched the National Drug Abuse Clinical Trials Network (CTN) to rapidly and efficiently test the effectiveness of behavioral and pharmacological treatments in real-life settings; and NIDA released its pamphlet Principles of Drug Addiction Treatment: A Research-Based Guide.

www.drugabuse.gov Principles of Drug Addiction Treatment
Three decades of scientific research and clinical practice have yielded a variety of effective approaches to drug addiction treatment. In April 1998, NIDA held The National Conference on Drug Addiction Treatment: From Research to Practice which summarized this extensive body of research. Based on the findings reported at this conference, NIDA published in October 1999, Principles of Drug Addiction Treatment: A Research-Based Guide to foster more widespread use of scientifically-based components of drug addiction treatment. Key components of this guide are highlighted in the following slides.

Addiction Research Basic Science Research Clinical Research
Epidemiological Research Research into Medical Complications (liver disease, HIV, FAS/FAE, cancer) Health Services Research Brandeis, Penn, Brown, BU, Dartmouth, UCLA, et al.

Sen. Harold Hughes Governor of Iowa (R) 1963-69
U.S. Senator from Iowa (D) Member of AA: onward Wikipedia: As a U.S. Senator, Hughes persuaded the Chairman of the Senate’s Labor and Public Welfare Committee to establish a Special Sub-committee on Alcoholism and Narcotics, chaired by Hughes himself. This subcommittee, which gave unprecedented attention to the subject, held public hearings on July 23–25, A number of people in recovery testified, including Academy Award-winning actress Mercedes McCambridge, National Council on Alcoholism founder Marty Mann, and AA co-founder Bill W. The hearings were considered a threat to anonymity and sobriety. Hughes also talked about the need for treatment of drug addiction. He stated that "treatment is virtually nonexistent because addiction is not recognized as an illness."

The Creation of NIAAA The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 –also known as the Hughes Act– is signed into law by President Richard M. Nixon on December 31, This legislation authorized a comprehensive Federal program to address prevention and treatment of alcohol abuse and alcoholism. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) was first established as a component of the National Institute of Mental Health (NIMH). It then became a separate institute alongside NIMH and NIDA under ADAMHA, the Alcohol, Drug Abuse, and Mental Health Administration. Since 1974, the NIAAA has been an independent Institute of the National Institutes of Health.

NIAAA Milestones 1971—First Special Report to the U.S. Congress on Alcohol and Health issued. 1981—U.S. Surgeon General’s Advisory on Alcohol and Pregnancy published. 1988—Federal minimum legal drinking age law instituted. 1989—Collaborative Studies on Genetics of Alcoholism (COGA) initiated. 1991—National Longitudinal Alcohol Epidemiologic Survey (NLAES) launched. 1999—First National Alcohol Screening Day. 2001—National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) launched. 2005—NIAAA releases Helping Patients Who Drink Too Much: A Clinician's Guide. 2007— NIAAA releases The Surgeon General's Call to Action to Prevent and Reduce Underage Drinking. 2007—NIAAA shares an Emmy award with HBO, NIDA, and the Robert Wood Johnson Foundation for The Addiction Project. [ Note: At the behest of ASAM President Mike Miller, MD, ASAM establishes its Media Award, given annually; the first recipient, in 2008, was producer John Hoffman for his HBO series "ADDICTION" ; the latest awardee, in 2014, was producer Greg Williams, for his documentary Anonymous People ]

Addiction Treatment is Politicized in the US—so Policy Matters
Harrison Act of 1914—made it a crime for any physician to treat a person with opioid addiction or opioid withdrawal with an opioid: the criminalization of medical practice of the non-person: the addict, the pariah Not until methadone was approved in and only for use in highly regulated clinics—was there an exception The Drug Addiction Treatment Act of 2000—known as DATA 2000—offers the only other exception to the Harrison Act, permitting the use of Schedule III buprenorphine by “waivered physicians”

National Drug Control Policy
In 1968, under President Johnson, the Bureau of Narcotics in the Department of the Treasury, which had jurisdiction over marijuana and heroin, was merged with the Bureau of Drug Abuse Control in the Department of Health, Education and Welfare (DHEW), which had jurisdiction over sedatives, stimulants, and hallucinogens, to create the Bureau of Narcotics and Dangerous Drugs (BNDD), the precursor of the DEA. It was placed under the Department of Justice.

Comprehensive Drug Abuse Prevention and Control Act (1970)
Title II of the Act was the Controlled Substances Act (CSA) which established the five Schedules of Controlled Substances and required manufacturers to maintain security over the supply chain. The Drug Enforcement Administration (DEA) was created by President Richard Nixon through an Executive Order in July 1973 in order to establish a single unified command to combat "an all-out global war on the drug menace." At its outset, DEA had 1,470 Special Agents and a budget of less than $75 million. Today, the DEA has nearly 5,000 Special Agents and a budget of $2.02 billion. (

Methadone Developed in 1937 in Germany by scientists working for the forerunner of Hoechst Pharmaceuticals, who were looking for a synthetic opioid to solve Germany's opium shortage problem: Dolophine ®. Methadone was introduced into the United States in 1947 by Lilly Pharmaceuticals as an analgesic. Studied by Dole, Nyswander and Kreek at Rockefeller University, New York. Levomethadone is a full µ-opioid agonist. Dextromethadone does not affect opioid receptor but binds to the glutamatergic NMDA (N-methyl-D-aspartate) receptor as an antagonist. The FDA approved methadone as a Schedule II drug for the treatment of opioid addiction in 1972.

Wikipedia on Methadone
“To date, methadone maintenance therapy has been the most systematically studied and most successful, and most politically polarizing, of any pharmacotherapy for the treatment of drug addiction patients.” In 2006, the U.S. Food and Drug Administration issued a caution about methadone, titled “Methadone Use for Pain Control May Result in Death.” Now: 16,000 opioid overdose deaths per year, 1/3 are due to methadone.

The Role of the AMA 1956 – appropriate for members of hospital medical staffs to admit alcoholics to general hospitals H Admission of Alcoholics to General Hospitals The AMA encourages insurance companies and prepayment plans to remove unrealistic limitations on the extent of coverage afforded for the treatment of alcoholism, recognizing that alcoholism is a chronic illness and that multiple hospital admissions under medical supervision may be essential to arresting the progress of the disease. (CMS Rep. G, I-66; Reaffirmed: CLRPD Rep. C, A-88; Reaffirmed: Sunset Report, I-98; Reaffirmed: CSAPH Rep. 2, A-08) H Drug Dependencies as Diseases The AMA (1) endorses the proposition that drug dependencies, including alcoholism, are diseases and that their treatment is a legitimate part of medical practice, and (2) encourages physicians, other health professionals, medical and other health related organizations, and government and other policymakers to become more well informed about drug dependencies, and to base their policies and activities on the recognition that drug dependencies are, in fact, diseases .(Res. 113, A-87; Reaffirmed by CSA Rep. 14, A-97; Reaffirmed: Sunset Report, I-97 Reaffirmed: CME Rep. 10, I-98; Reaffirmed: CME Rep. 11, A-07 H Drug Abuse in the United States - the Next Generation ... (6) urges that public policy be predicated on the understanding that alcoholism and drug dependence, including tobacco dependence as indicated by the Surgeon General's report, are diseases... (BOT Rep. Y, I-89; Reaffirmed: Sunset Report, A-00; Reaffirmation A-09)

The Role of the AMA H Alcoholism as a Disability (1) The AMA believes it is important for professionals and laymen alike to recognize that alcoholism is in and of itself a disabling and handicapping condition. (CSA Rep. H, I-80; Reaffirmed: CLRPD Rep. B, I-90; Reaffirmed by CSA Rep. 14, A-97; Reaffirmed: CSAPH Rep. 3, A-07) H Dual Disease Classification of Alcoholism The AMA reaffirms its policy endorsing the dual classification of alcoholism under both the psychiatric and medical sections of the International Classification of Diseases. (Res. 22, I-79; Reaffirmed: CLRPD Rep. B, I-89; Reaffirmed: CLRPD Rep. B, I-90; Reaffirmed by CSA Rep. 14, A-97; Reaffirmed: CSAPH Rep. 3, A-07) H Recommendations for AMA Involvement in Alcoholism Activities To further emphasize the seriousness of alcoholism and the importance of the physician's role in prevention and treatment of this disease, our AMA: encourages relevant medical specialty societies to inform their membership about opportunities for treatment and early intervention, especially among women alcoholics and children of alcoholics; reaffirms that effective and comprehensive treatment for alcoholic persons requires the involvement of a physician; and urges that quality of treatment not be sacrificed to cost considerations. (CSA Rep. E, A-79; Reaffirmed: CLRPD Rep. B, I-89; Reaffirmed: Sunset Report, A-00; Reaffirmed: CSAPH Rep. 1, A-10)

The Role of the AMA H Education Regarding Prescribing Controlled Substances The AMA (1) encourages physicians, hospital medical staff organizations, resident physicians, and medical students to participate in education programs to ensure proper prescribing and dispensing of controlled substances; and (2) encourages regulatory agencies, state medical societies, and state medical boards to recognize the value of participation in such educational programs as an alternative to imposing disciplinary sanctions on well-intentioned physicians. (Sub. Res. 76, I-88; Reaffirmed: Sunset Report, I-98; Reaffirmed: CME Rep. 2, A-08) H Role of Self-Help in Addiction Treatment The AMA: (1) recognizes that (a) patients in need of treatment for alcohol or other drug-related disorders should be treated for these medical conditions by qualified professionals in a manner consonant with accepted practice guidelines and patient placement criteria; and (b) self-help groups are valuable resources for many patients and their families and should be utilized by physicians as adjuncts to a treatment plan; and (2) urges managed care organizations and insurers to consider self-help as a complement to, not a substitute for, treatment directed by professionals, and to refrain from using their patient’s involvement in self-help activities as a basis for denying authorization for payment for professional treatment of patients and their families who need such care. (Res. 713, A-98; Reaffirmed: CSAPH Rep. 2, A-08)

What did the AMA say in 1956? “Resolution on Hospitalization of Patients with Alcoholism” drafted by the Committee on Alcoholism of the AMA Council on Mental Health Presented its resolution to the AMA Board of Trustees for approval in June, 1956. “The Council on Mental Health, its Committee on Alcoholism, and the profession in general recognizes this syndrome of alcoholism as illness which justifiably should have the attention of physicians.”

What did the AMA say in 1956? “Among the numerous personality disorders encountered in the general population, it has long been recognized that a vast number of such disorders are characterized by the outstanding sign of excessive alcohol use. All excessive users of alcohol are not diagnosed as alcoholics, but all alcoholics are excessive users.” Proceedings, Clinical Session of the AMA House of Delegates, 1956

What did the AMA say in 1956? “One of the most consistent complaints of physicians who wish to care for these patients is that many hospitals will not admit such patients with a diagnosis of alcoholism. Many feel that these people are intractable, uncooperative, and difficult to handle. Because of their untoward behavior, hospital authorities feel they are not equipped to take care of the medical treatment of such overactive patients. ” Proceedings, Clinical Session of the AMA House of Delegates, 1956

What did the AMA say in 1956? “Where such patients are unruly and uncooperative, this attitude is understandable. However, for many…, cooperation is forthcoming and…no special attention or equipment is necessary for treating these patients. Hospitals should be urged to consider admission of such patients with a diagnosis of alcoholism based upon the condition of the individual patient rather than a general objection to all such patients. ” Proceedings, Clinical Session of the AMA House of Delegates, 1956

What did the AMA say in 1956? “Chronic alcoholism should not be considered as an illness which bars admission to a hospital, but rather as a qualification for admission when the patient requests such admission and is cooperative….” Proceedings, Clinical Session of the AMA House of Delegates, 1956

What did the AMA say in 1956? “Alcoholic symptomatology and complications which occur in many personality disorders come within the scope of medical practice.” “Since the house officer in a hospital will eventually come in contact with this type of patient in practice, his training in treating this illness should come while he is a resident officer.” Proceedings, Clinical Session of the AMA House of Delegates, 1956

What did the AMA say in 1956? “In order to accomplish any degree of success with the problem of alcoholism, it is necessary that educational programs be enlarged, methods of case finding and follow-up be ascertained, research be encouraged and general education toward acceptance of these sick people for treatment must be emphasized.” Proceedings, Clinical Session of the AMA House of Delegates, 1956

What did the AMA say in 1956? The House of Delegates adopted a report of the Council on Medical Service on admission of alcoholics to general hospitals with the following recommendations: “That state medical associations and component medical societies establish liaison and work with hospital medical staffs and with state and local hospital associations to implement the 1956 statement of the Council on Mental Health. “That the 1956 statement…be resubmitted to the Joint Commission on Accreditation of Hospitals with the request that it give all possible assistance in implementing the statement…” “Digest of Official Actions of the AMA House of Delegates, , Volume 2, publication date 1971.

What did the AMA say in 1956? “That insurance companies and prepayment plans be encouraged to remove unrealistic limitations on the extent of coverage afforded for the treatment of alcoholism, recognizing that alcoholism is a medical illness and that multiple hospital admission under medical supervision may be essential to arresting the progress of this disease.” Digest of Official Actions of the AMA House of Delegates, , Volume 2, publication date 1971.

What did the AMA say in 1967? The House of Delegates adopted Resolution 48 identifying alcoholism as a complex disease and as such recognizing that the medical components are medicine’s responsibility….” Digest of Official Actions of the AMA House of Delegates, , Volume 2, publication date 1971.

Advocacy for Alcoholism
The National Council on Alcoholism (NCA), now NCADD NCADD is the leading advocacy organization in the world addressing alcoholism and drug dependence. Since 1944, NCADD has raised public awareness about addiction throughout the United States and increasingly across the global community. NCADD’s founder, Marty Mann, believed alcoholism was a disease, that it could be treated and it should be treated like a public health problem. Marty advocated this belief strongly to the medical and scientific community. The foundation of NCADD was built on three simple ideas: Alcoholism is a disease and the alcoholic is a sick person; The alcoholic can be helped and is worth helping; This is a public health problem and therefore a public responsibility.

“Our Founder.” Marty Mann was an alcoholic. Plain and simple. She admitted it and once sober she dedicated the rest of her life to help others who suffered from the same crippling, often fatal, disease. Educating an ignorant public drove her every day to eradicate the stigma of addiction.

Marty came from privilege, born in 1905 into a wealthy Chicago family and attended the best private schools. Married at 22, divorced at 23, Marty was a drunk at 24, around the same time her father lost his fortune. Attractive, intelligent, engaging with a sharp wit and a flair for parties, things came easy for Marty and drinking was increasingly part of the picture. Despite her strong will power, she could not stop drinking. Then, in 1934, Marty fell from a small balcony during a party. She never knew if she fell or jumped. A fractured leg, a broken jaw and traction for six months did not stop her from continuing to drink. Out of money, jobs gained and lost, Marty wound up in a secluded corner of Hyde Park in London, sipping booze from a bottle. She was close to hitting her bottom.

Advocacy Faces and Voices of Recovery (FAVOR)
National Alliance of Advocates for Buprenorphine Treatment (NAABT) National Alliance for Medication Assisted Recovery ( – formerly National Alliance of Methadone Advocates (Division of Pharmacologic Therapies)

History—Professional Societies
ASAM – founded 1954 Name becomes ASAM – 1989 ASAM

Non-Physician and Multi-Disciplinary Professional Associations
Association for Medical Education and Research in Substance Abuse (AMERSA)

Physician Specialty Associations
American Osteopathic Academy of Addiction Medicine American Academy of Addiction Psychiatry--1987

Researchers’ Societies
AMERSA Research Society on Alcoholism (RSA) –37th annual meeting in 2014: College on Problems on Drug Dependence (CPDD) -- until 1991, “Committee on….” Founded 1929 as part of National Academy of Sciences, National Research Council Independent membership organization since 1976

ASAM/CSAM: The Early Years
1951: New York City Medical Committee on Alcoholism established. (Under NCA; Marty Mann, Ruth Fox collaboration). 1954: New York City Medical Society on Alcoholism’s (NYCMSA) first scientific meeting, September 16, 1954 at New York Academy of Medicine. 1967 (September): The New York City Medical Society on Alcoholism becomes the American Medical Society on Alcoholism (AMSA)—it served as the Medical-Scientific Committee of NCA, with offices housed at NCA in NYC. 1972: California Society for the Treatment of Alcoholism and Other Drug Dependencies incorporated (CSTOADD)– offices housed at CMA headquarters.

www.asam.org The Founders The Early Presidents
Ruth Fox, MD Founding President President , Stanley E. Gitlow, MD President , Luther A. Cloud, MD President Percy E. Ryberg, MD President Sheila B. Blume, MD President Max A. Schneider, MD President Jasper G. Chen See, MD President David E. Smith, MD, FASAM President G. Douglas Talbott, MD, FASAM President

Medical Societies Contribute to Progress Toward Recognition
1954: The goals of the NYCMSA were to gain recognition of alcoholism as a treatable disease and to persuade hospitals to admit patients with a diagnosis of alcoholism, which at that time many refused to do so; Ruth Fox did not admit her alcohol withdrawal patients to a hospital due to this stigma/discrimination 1956: the AMA stated that it was appropriate to treat alcoholics in hospitals. 1971: The National Institutes of Health created the Career Teacher Program in the addictions, supported by faculty development grants to 63 medical schools (Jean Trumble and Jim Callahan were co-chairs of the CTP)

Medical Societies Contribute to Progress Toward Recognition
1972: The California Society for the Treatment of Alcoholism and Other Drug Dependencies (CSTAODD) was incorporated (with support from the California Medical Association), to focus on medical education and certifying physician competency in the addictions 1975: The American Academy of Addictionology was organized by G. Douglas Talbot, M.D., and other leaders in Georgia and in the Southeastern U.S. to certify physicians in Chemical Dependency

Progress Toward Medical Specialty Recognition
1976: Development of curriculum guides for medical schools was supported by the National Institute on Drug Abuse (NIDA). The Association for Medical Education in Substance Abuse (AMERSA) was founded (Ed Senay said there were 78 physician specialists at the founding). 1977: AMSA began to publish Alcoholism: Clinical & Experimental Research (the “Blue Journal”) in partnership with the National Council on Alcoholism (NCA) and the Research Society on Alcoholism (RSA). A:CER was AMSA’s official journal for almost 15 years and remains RSA’s official journal.

1982: The California Society for the Treatment of Alcohol and Other Drug Dependencies (CSTAODD) launched a certification program, spurred in part by state legislation requiring that physicians who direct addiction treatment programs must be able to demonstrate expertise in that subject. 1982: The American Medical Association endorsed the concept that a single organization should provide an umbrella for the multiple existing societies (in California, New York, and Georgia) to become a single national medical specialty society for Addiction Medicine.

The Unity Meetings Kroc Ranch
AMSA, CSTOADD, AAA come together AMSA focused on alcoholism and was headquartered in the Northeast; but Chicago had a major contingent (Ed Senay, MD) The Illinois Drug Abuse Program (IDAP) had been founded when Jerome Jaffe, MD, moved from the Lexington Hospital to the University of Chicago under Daniel X. Friedman, MD; Ed Senay joined Jerry Jaffe in 1969 and methadone came to Chicago)

1983: At the first Kroc Ranch unity meeting, addiction field leaders agreed that a single national medical specialty society should represent the field. 1985: At a second Kroc Ranch meeting (convened by the AMA), the conferees accepted AMSA’s offer “to be the national society of physicians concerned with problems of psychoactive drug use.”

The Unity Meetings at the Kroc Ranch: AMSA-CSTAODD-AAA
CSTAODD included alcohol and drug treatment experts (including methadone and “drug-free outpatient”) but also included nicotine/tobacco experts The American Academy of Addictionology, founded by Doug Talbott, MD, included primarily recovering physicians who had been treated by Dr. Talbott and who practiced in facilities throughout the Southeastern U.S.

Doug Talbott G. Douglas Talbott, MD, is a graduate of Yale University and received his medical degree from the Columbia University College of Physicians and Surgeons. Dr. Talbott began his career as a cardiologist. Dr. Talbott founded and became Director of the Cox Heart Institute, a nationally recognized cardiac research institute, and also worked with the National Aeronautics and Space Administration (NASA) to select suitable crew for the Mercury, Apollo and Gemini Space Programs.

Doug Talbott Founded Talbott Recovery Campus—the leading treatment program and model for physicians with addiction Pioneer, with Roger Goetz, MD, of Florida, of Physician Health Programs – now there is a Federation of State Physician Health Programs, FSPHP Founded the American Academy of Addictionology at the second meeting of the AMA’s Physician Health Committee Served as President of the American Society of Addiction Medicine (ASAM) and Vice President and USA Representative of the International Society of Addiction Medicine (ISAM). His nephew is Nelson Strobridge "Strobe" Talbott III. With the facilitation of his nephew, Doug travelled often to the USSR and helped promote A.A. in Russia

Nelson Strobridge "Strobe" Talbott III Through the 1980s he was Time magazine's principal correspondent on Soviet-American relations, and his work for the magazine was cited in the three Overseas Press Club Awards won by Time in the 1980s. Talbott also wrote several books on disarmament. He is currently the president of the Brookings Institution in Washington, D.C., and a member of the Council on Foreign Relations. He is a former Deputy Secretary of State and after the Soviet breakup served as Ambassador-at-Large and Special Adviser to the Secretary of State Warren Christopher on the new independent states of the former USSR.

The Evolution of Recognition of ADM
1988 (A-88): ASAM is approved and accepted into membership by the House of Delegates of the American Medical Association (AMA) as a national medical specialty society; the AMA Resolution to achieve this milestone was authored by the California Medical Association (CMA) at the behest of the San Francisco (County) Medical Society NOTE: New York was the “founder” of the unified national Society, but California was the inspiration for “the big tent”— Jess Bromley of the East Bay became ASAM’s first Delegate to the AMA in 1988 and David Smith of San Francisco became ASAM’s first Alternate Delegate (Jess was succeeded by Mike Miller of Wisconsin in 1995) (A-90): The AMA House of Delegates acts to assign addiction medicine a code as a self-designated practice specialty in the AMA Physician Masterfile by approving a resolution inspired by ASAM and introduced by the California Medical Association. The code (ADM) is officially is officially approved by the AMA Board of Trustees in July.

The Legacy of the Unity Meetings AMSAODD becomes ASAM
The merger of AMSA and the California Society and the American Academy of Addictionology became AMSAODD: the American Medical Society on Alcoholism and Other Drug Dependencies AMSAODD changed its name to ASAM in 1988, named an Executive Director (Manny Steindler; part-time, in Chicago), took over the certification process from California Society, and partnered with NAATP in the development of Placement Criteria. Jim Callahan, DPA, became the first full-time Exec Dir (then EVP/CEO) and moved the offices to Washington, DC area ASAM offered National Conferences on Nicotine Dependence (1988, 1990) and on Patient Placement Criteria (1991, 1992, 1993)

Milestones in ASAM’s Adolescence
1990: ASAM Board approves the ASAM Guidelines for Fellowship Training Programs in Addiction Medicine (amended 1992), developed by the ASAM Fellowship Committee. 1991: ASAM President Jasper Chen See, M.D., established the Ruth Fox Memorial Endowment Fund to support ASAM’s mission and goals. The Journal of Addictive Diseases, edited by academic internist Barry Stimmel, M.D., FASAM, of Mt. Sinai (NY) became ASAM’s official journal, replacing A:CER. ASAM published the first edition of its Patient Placement Criteria for the Treatment of Psychoactive Substance Use Disorders (PPC), which quickly became the standard for the field. 1993: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) awarded Addiction Medicine a representative on its Hospital Accreditation Program (HAP) Professional and Technical Advisory Committee (PTAC)—joint seat of NAATP, NAADAC and ASAM (Mee Lee 93-94; Miller 95-98) 1994: ASAM is awarded its own seat on the JCAHO’s Accreditation Program for Behavioral Health Care PTAC. 1994: Principles of Addiction Medicine published by ASAM

Physician Certification
: The California Society (CSTAODD) develops a Certification Examination The California Society contracts with the NBME to assure the quality of the exam The California Society donates the exam to AMSAODD : AMSAODD/ASAM offers the exam, then does so every other year through 2008 1993: For Board Certified Psychiatrists only the American Board of Psychiatry and Neurology (ABPN) begins offering a certification examination leading to an ABMS-recognized credential (ADP) 1997: The National Committee for Quality Assurance (NCQA) adopted a requirement that NCQA-accredited managed behavioral health care organizations must have standards for credentialing “psychiatrists and/or physicians certified in Addiction Medicine.” 2009: ASAM donates the exam to ABAM 2010, 2012, 2014: ABAM offers the exam

The History of Addiction Medicine
David Smith on the Evolution of Addiction Medicine as a Medical Specialty

Addiction Psychiatry As of October 1991, the American Board of Psychiatry and Neurology (ABPN) and the American Board of Medical Specialties (ABMS), with support of the American Psychiatric Association, established a "Committee on Certification of Added Qualifications in Addiction Psychiatry." This was a way to identify the most educated and experienced psychiatrists in the profession Diplomates admitted in 1994 via the first ADP (Addiction Psychiatry) exam, given in late 1993—initially called CAQ rather than ‘Subspecialty Certification’ Years later, in 1997, the committee's board of trustees along with the ABMS renamed the committee "Committee on Certification in the Subspecialty of Addiction Psychiatry." The committee became more geared toward developing the subspecialty of addiction psychiatry. As of 1997, there were only 13 addiction psychiatry programs that the Accreditation Council for Graduate Medical Education (ACGME) recognized. Currently the ACGME recognizes 45 different residency programs in the United States.

Relationship Between Alcohol Use and Alcohol Problems
None Light Moderate Heavy Low Risk At Risk Problem Dependent Severe Moderate Small None Alcohol Problems

The Spectrum of Alcohol Use
heavy Alcohol Use Disorders severe Alcoholism Dependence Unhealthy Use Alcohol Abuse Problems = Harmful consumption consequences Risky: At Risk of Harms Low risk use none Abstinence none

“Broadening the Base of Treatment” IOM Report--1990
303.90 Levels of USE 305.00 Problem Use Risky Use TREATMENT INTENSITY Use none Abstinence / Non-Use none

Broadening the Base Pay attention to more than “addiction”
There is a role for the primary care physician in the evaluation and management of alcohol problems Early identification leads to early intervention Results are better with intervention is early in the course of the condition: don’t just treat end-stage problems

Substance Related Health Conditions
Substance Intoxication Substance Withdrawal Substance Use Disorders Substance Abuse Substance Dependence Substance Induced Disorders Psychiatric Complications/Co-morbidities General Medical Complications/Conditions

Physicians Should attend to Sub-Syndromal Substance Use
Unhealthy Alcohol Use = Addiction (Alcohol Dependence--DSM-IV; Alcohol Use Disorder, Moderate or Severe—DSM-5: 303.9) Harmful Use (includes Addiction plus the former Alcohol Abuse from DSM-IV, i.e., Alcohol Use Disorder, Mild, from DSM-5: 305.0; but also Problem Use; problems/harms already present) Hazardous Use (Risky Use/At-Risk Use); no harms yet, but risk for development of harm

ASAM Definitions (from DDTAG)
Unhealthy use of alcohol and other drug (substance) is any use that increases the risk or likelihood for health consequences (hazardous use), or has already led to health consequences (harmful use). Hazardous use (alternatively, At-Risk use) : Use that increases the risk for health consequences. HEAVY DRINKING vs. ADDICTIVE DRINKING

History has brought us to this point in time
What is “Addiction Treatment” circa 2014? Modalities Goals: targeted outcomes of treatment

What are we trying to accomplish through “Professional Treatment?”
ASAM Public Policy Statement on Treatment for Alcohol and Other Drug Addiction Addiction Treatment is the use of any planned, intentional intervention in the health, behavior, personal and/or family life of an individual suffering from alcoholism or from another drug addiction, and which is designed to enable the affected individual to achieve and maintain sobriety, physical, spiritual and mental health, and a maximum functional ability. Addiction Treatment services are professional healthcare services, offered to a person diagnosed with addiction, or to that person’s family, by an addiction professional. Addiction professionals providing addiction treatment services are licensed or certified to practice in their local jurisdiction and may be nationally certified by a professional certification body for their professional discipline. Adopted by ASAM Board of Directors May 1980; revised September 1986, October 1997, July 2001, October 2009, and January 2010.

Non-Pharmacological Tx
Addiction Counseling (supportive / RET / confrontational) Cognitive Behavioral Therapy (CBT) Coping Skills Training Recreational Therapy Psychoanalytically-oriented Psychotherapy Motivational Enhancement Therapy (MET) Community Reinforcement Approach (CRAFT) Twelve-Step Facilitation (TSF) Network Therapy Behavioral Therapy Aversion Therapy

www.drugabuse.gov Principles of Drug Addiction Treatment
Three decades of scientific research and clinical practice have yielded a variety of effective approaches to drug addiction treatment. In April 1998, NIDA held The National Conference on Drug Addiction Treatment: From Research to Practice which summarized this extensive body of research. Based on the findings reported at this conference, NIDA published in October 1999, Principles of Drug Addiction Treatment: A Research-Based Guide to foster more widespread use of scientifically-based components of drug addiction treatment. Key components of this guide are highlighted in the following slides.

NIDA Principles of Drug Addiction Treatment (1999, rev 2009)
1. Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased. 2. No single treatment is appropriate for everyone. NIH Publication No. 09–4180

In some cases of addiction, medication management can improve treatment outcomes.
In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results. Chronic disease management is important for minimization of episodes of relapse and their impact. Treatment of addiction saves lives

Using DRUGS to treat Drug Addiction

Addiction Nicotine—pharmacotherapy is available
Opioids—pharmacotherapy is available Alcohol—pharmacotherapy is available Sedatives Stimulants Cannabinoids Hallucinogens Inhalants Gambling

Overview of Pharmacotherapies for Addiction
Antabuse—for alcohol addiction Naltrexone, acamprosate, topiramate, et al.—for alcohol addiction Naltrexone—for opioid addiction Opioid Agonist Therapies—MMT O.B.O.T.—buprenorphine N.R.T., bupropion, varenicline—for nicotine addiction

The NIAAA Clinician’s Guide

DSM has no descriptions of “sub-syndromal use” that is harmful or risky
Substance Use Disorder—severe Substance Use Disorder—moderate Substance Use Disorder—mild But what about harmful use that doesn’t meet 2 or more criteria—and thus is not a ‘disorder’? And what about risky use that hasn’t led to harm but carries probability of doing so? SBIRT -- Level 0.5 care in The ASAM Criteria

Unhealthy Alcohol Use Addiction (Alcohol Dependence--DSM-IV; Alcohol Use Disorder, Moderate or Severe—DSM-5: 303.9) Harmful Use (includes the former Alcohol Abuse from DSM-IV, i.e., Alcohol Use Disorder, Mild, from DSM-5: 305.0; but also Problem Use; problems/harms already present) Hazardous Use (Risky Use/At-Risk Use); no harms yet, but risk for development of harm

ASAM Definitions (from DDTAG)
Unhealthy use of alcohol and other drug (substance) is any use that increases the risk or likelihood for health consequences (hazardous use), or has already led to health consequences (harmful use). Hazardous use (alternatively, At-Risk use) : Use that increases the risk for health consequences. HEAVY DRINKING vs. ADDICTIVE DRINKING

The ASAM Criteria and ASAM Criteria Software

The ASAM Criteria Intensity of Service should derive from Severity of Illness Treatment should follow multidimensional Assessment Diagnosis—Treatment Plan—Determination of Level of Care

Assessment Dimensions
Intoxication/Withdrawal Potential Biomedical Conditions/Complications Emotional/Behavioral/Cognitive Conditions Treatment Acceptance/Readiness/Motivation Relapse/Continued Use Potential Recovery Environment

Levels of Care 0.5 Screening/Brief Intervention/Education
1.0 General Outpatient 2.0 Intensive Outpatient/Partial Hospital 3.0 Medically Monitored/Residential halfway houses, extended care, TC’s 4.0 Medically Managed/Inpatient

The Role of the Physician in the Care of Addiction and Other Substance Related Disorders

Addiction Specialist Physician
Addiction specialist physicians include addiction medicine physicians and addiction psychiatrists who hold either a board certification in addiction medicine from the American Board of Addiction Medicine (ABAM), a subspecialty board certification in addiction psychiatry from the American Board of Psychiatry and Neurology (ABPN), a subspecialty board certification in addiction medicine from the American Osteopathic Association (AOA), or certification in addiction medicine from the American Society of Addition Medicine (ASAM).

The Role of the Physician
We made a good faith effort to differentiate the role of the physician in the Criteria themselves, under the Staffing section describing each Level of Care (and sub-level) We tried to understand: Where is a physician needed—vs. a PA or APNP? Where is an addiction medicine physician needed—vs. a non-specialist physician? Where is an addiction psychiatrist needed?

Treating All Patients Like We Treat Doctors who have Addiction
Contingencies Structure and Accountability Chronic Disease Management Monitoring Treatment monitoring Laboratory monitoring Workplace monitoring Adequate Dose and Duration: 2-5 years

Treatment of Addiction
What are the treatment goals for a chronic disease? Decrease frequency of relapses Decrease severity of relapses Increase duration of remission Optimize level of function during remissions

Examples of C.D.M. A-I-R.com (AiR) Caron’s Recovery Care Services
Program specialists get to know patients while in treatment, and right before discharge, the Recovery Care Services Specialist meets with the patient to enroll in the program. Monthly phone calls to patients allow Caron RCS Specialists to track many aspects of a patient’s ongoing recovery and provide problem solving, coaching, and intervention-based approaches, as appropriate.

Examples of C.D.M. Hazelden’s MORE program:
MORE months of effective, personalized recovery support. MORE connects you with the tools, support, and fellowship you need to build your new life in recovery. Think of MORE as a personal guide for your recovery journey. Recovery tools: worksheets, journaling, fact sheets, articles, videos MORE supports you with Guidance from your recovery coach, a licensed addiction counselor, both electronically and by phone Encouragement to set and reach personal commitments each week Spiritual insights and inspiration through an online Serenity Room MORE connects you with Online, real-time discussion boards with Hazelden alumni

Examples of C.D.M. Alcohol Research & Health, Volume 33, Number 4 (2009) Treating Alcoholism As a Chronic Disease: Approaches to Long-Term Continuing Care James R. McKay, Ph.D., and Susanne Hiller-Sturmhöfel, Ph.D. JAMES R. MCKAY, PH.D., is a professor in the Department of Psychiatry, University of Pennsylvania, and director of the Philadelphia VAMC Center of Excellence in Substance Abuse Treatment and Education, both in Philadelphia, Pennsylvania. SUSANNEHILLER-STURMHÖFEL, PH.D., is senior science editor with Alcohol Research & Health (NIAAA)

Addiction Treatment Offered by addiction specialists:
A continuum of care, as described in The ASAM Criteria Level I, II, III, IV Many patients receive IOP as “primary treatment” Offered by addiction specialist physicians A combination of psychosocial services, in a continuum based on medical necessity, with evidence-based pharmacotherapy

Addiction Treatment Offered by researchers:
Virtually never anything beyond ASAM Level I Various pharmacotherapies (clinical trials) Various individual therapies Infrequently group or family therapy Often 12 sessions or less

Addiction Treatment Offered by mental health therapists:
Mental health therapy Usually individual therapy CBT, MET, coping skills training Occasionally TSF; more often just referral to AA

Addiction Treatment Offered by primary care physicians:
Treatment of medical (or psychiatric) complications of addiction General support Maybe medication management If sophisticated: SBIRT using MET At times, referral (outside) to an addiction counselor At times, referral to AA At times, referral to ‘specialty addiction care’

Addiction Treatment As approved by “managed care”
“fewer visits” is better “stabilization/crisis management” then “go to AA” or “fend for yourself” Anything but “chronic disease management” Transitioning to…. Generate results (reduce readmissions) Truly manage health status/population outcomes Increase utilization of ADM services to decrease utilization of med/surg services

Living History—As It Happens!
Current trends Pharmacotherapy Reactions to “Pharmacotherapy Only” LMD (“Like Minded Docs”) C.O.R.E.

Current trends Improving Treatment via Improving Education The ABAM Foundation: subspecialty GME C.O.P.E.—imbedding improved education in all undergraduate and graduate medical education

Current trends Attention to the “Heavy Drinker” Saving Costs by Reducing Medical Complications of Heavy Drinking Treatment = Prevention Saving Lives by Reducing Medical Complication of Drug Use (IVDU) “Harm Reduction”

Current trends “Medicalization” – have PHYSICIANS involved CASA Report Do what doctors do: diagnose, medicate, consult Integration of Addiction Care and Primary Care Integration “Reverse Integration” Help Doctors to become Part of the Solution, not Part of the Problem Improved prescribing practices for opioids SBIRT by physicians – primary care, med/surg specialties, psychiatrists

Current trends True Integration Not just “addiction care” and “medical care” Addiction Care and Mental Health Care Not just alcoholism care and drug addiction care but also nicotine/tobacco addiction care Not just “medical care” by physicians, but “health care” and “health promotion” by health care teams (physicians integrated into physician-led teams)

Treat Addiction Save Lives © ASAM

800-767-4411 rogershospital.org Michael M. Miller, MD, FASAM, FAPA
rogershospital.org

The Herrington Recovery Center

Thank you! Michael M. Miller, MD, FASAM, FAPA Medical Director
Herrington Recovery Center

Life. Worth. Living. Rogers Memorial Hospital
Wisconsin’s largest not-for-profit behavioral health care provider Inpatient  Residential  Partial Hospitalization  Day Treatment //

The Neurobiology of Addiction: It’s About Brains, It’s Not about Rewards / Relief / Drugs / Alcohol
Michael M. Miller, MD, FASAM, FAPA, Medical Director Herrington Recovery Center Rogers Memorial Hospital

Medical Director, Herrington Recovery Center (HRC) Rogers Memorial Hospital Oconomowoc, Wisconsin Clinical Adjunct Associate Professor University of Wisconsin School of Medicine and Public Health Assistant Clinical Professor Medical College of Wisconsin, Dept of Psychiatry & Behavioral Health Past President and Board Chair Wisconsin and American Societies of Addiction Medicine Director American Board of Addiction Medicine

ASAM’s Mission The American Society of Addiction Medicine’s mission is to: Increase access to and improve the quality of addiction treatment; Educate physicians (including medical and osteopathic students), other health care providers and the public; Support research and prevention; Promote the appropriate role of the physician in the care of patients with addiction; Establish addiction medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of health care services, and the general public. Approved by ASAM Board, ;

Addiction Medicine: The specialty of medicine devoted to diagnosis, treatment, prevention, education, epidemiology, research, and public policy advocacy regarding addiction and other substance-related health conditions

Treat Addiction Save Lives © ASAM

How to Identify a Physician Recognized for Expertise in the Diagnosis and Treatment of Addiction and Substance-related Health Conditions (ASAM Public Policy Statement)

www.asam.org/HowToIdentifyaPhysicianRecognized forExpertness.html
Completion of a residency/fellowship in Addiction Medicine or Addiction Psychiatry Certification in Addiction Medicine by the American Society of Addiction Medicine (ASAM) Subspecialty certification in Addiction Psychiatry by the American Board of Psychiatry and Neurology (ABPN) A Certificate of Added Qualification in Addiction Medicine conferred by the American Osteopathic Association (AOA) Board Certification in Addiction Medicine by the American Board of Addiction Medicine (ABAM)

Scope of Practice for Addiction Medicine Physicians (ABAM)
The addiction medicine physician provides medical care within the bio-psycho-social framework for persons with addiction, for the individual with substance- related health conditions, for persons who manifest unhealthy substance use, and for family members whose health and functioning are affected by someone’s substance use or addiction.

Scope of Practice for Addiction Medicine Physicians (ABAM)
The addiction medicine physician is specifically trained in a wide range of prevention, evaluation and treatment modalities addressing substance use and addiction in ambulatory care settings, acute care and long-term care facilities, psychiatric settings, and residential facilities. Addiction medicine specialists often offer treatment for patients with addiction or unhealthy substance use who have co-occurring general medical and psychiatric conditions.

American Board of Addiction Medicine Mission Statement
ABAM’s mission is to contribute to the improvement of care for patients suffering from addiction to alcohol, nicotine and other addicting drugs (including some prescription drugs), and to establish and maintain standards and procedures for certification, recertification and maintenance of certification of physicians who specialize in Addiction Medicine.

The Irony... Addiction is not about DRUGS ! Addiction is about BRAINS!
It’s not about the quantify/frequency of use It’s about the Quality of use Pattern of use Relationship the person has to ‘their drug’ It’s about how the person with addiction is changed when using

The Physiology and Neuroanatomy of the Addicted Brain
Developmental Neuroanatomy and its Relevance to Addiction

The Physiology of the Addicted Brain
We used to talk about the Neuroanatomy of Addiction, but when we discussed ‘The Reward Center’ we really were talking about the neuroanatomy of Reward/Intoxication/Withdrawal We used to talk about Pharmacotherapy in Addiction, but that was a talk about psycho-pharmacology (the medication management of psychiatric complications/co-morbidities)

Now we can truly talk about the Neuroanatomy of Addiction, and we can talk about treatment as including not just psychosocial therapies (“drug rehab”), but also the pharmacotherapy of Addiction itself.

What’s the brain? (what are the relevant brain areas where physiology happens?) What are the agents? How do they act? What are the symphony of actions and interactions in an actively addicted brain?

How is it that DRUGS are different from broccoli?
It’s because of what ‘drugs’ do to the BRAIN Drugs enter the body via various routes Oral, Intravenous, Intramuscular, Intranasal, transdermal, transbuccal, or transalveolar Drugs that affect mood/thought/behavior cross the ‘blood brain barrier’ Drugs act on nerve cells by binding to specialized portions of the outer membrane of nerve cells

The Brain

The Synapse

Neuroanatomy…Neurophysiology… Neurochemistry
Nerve cells in the brain are interconnected segments in complex electrical circuitry, but the electrical activity between cells is chemically mediated Nerve cells ‘talk to each other’ by releasing a chemical that is ‘recognized’ by other nerve cells

The ‘gap’ between nerve cells is called the ‘synapse’
The nerve cell ‘sending the message’ is called the ‘pre-synaptic neuron’ The nerve cell ‘receiving the message’ is called the ‘post-synaptic neuron’ The pre-synaptic neuron synthesizes chemicals called ‘neurotransmitters’, stores them, and releases them The post-synaptic neuron has specialized locations on its outer membrane called ‘receptors’

The Synapse In Action

Neurotransmission

Neurotransmitters Mono-amines Serotonin Acetylcholine Amino acids
Epinephrine (adrenaline) Norepinephrine Dopamine Serotonin Acetylcholine Amino acids Gamma-amino-butyric acid (GABA) Glutamic acid (glutamate)

Neurotransmitters Countless others Amino Acids
Peptides (chains or polymers of amino acids) Proteins (polypeptides—chains of peptides) Hormones Nitric Oxide

Neurotransmitters The most common ones aren’t the ‘main’ ones that ‘send information’ along important circuits (e.g., DA, NE) The most common ones are the modulators, which are ubiquitous: GABA is the inhibitory neurotransmitter Glutamate is the excitatory neurotransmitter

Receptors Neurotransmitters wouldn’t ‘work’ unless there were a ‘receptor’ on the adjacent neuron to ‘receive’ the neurotransmitter and ‘react’ to its presence DA receptors NE receptors Serotonin receptors Nicotinic subtype of ACh (acetyl choline) receptors NMDA subtype of glutamate receptors GABA receptors

More on receptors Drugs (pharmaceuticals, ‘street’ drugs) would not ‘work’ unless they had a ‘place’ to work – they turn on receptors The mu (morphine) opioid receptor The CB1 and CB2 cannabinoid receptors The ‘benzodiazepine’ receptor (benzo’s enhance GABA’s ability to turn on the GABA receptor) The receptors aren’t there to receive information from external agents; there are internal chemicals that work on all these receptors (endorphins, endocannabinoids)

There are CNS Receptors for all these Drugs
Nicotine: Nicotinic Acetylcholine Receptors Opioids: mu, kappa, delta Cannabinoids: CB1, CB2 Cocaine: Dopamine receptors and transporters Stimulants: NE and 5-HT receptors “The GABA Receptor” (chloride channels) Glutamate Receptors, especially the NMDA subtype

And the chemists have long known that the brain doesn’t care…
…if it’s an endogenous ligand …if it’s a ‘natural’ ligand like morphine or THC …if it’s a synthetic ligand Like methadone, fentanyl, meperidine, buprenorphine Like zolpidem, zaleplon, or other BDZD-receptor agonists Like K2 or other CB1-receptor agonists

What about the Brain and its Development?
Infant Child Adolescent Adult

NIMH Study Findings Extensive structural changes occur well past puberty, which relate to functional changes associated with development Piaget: Formal Operational Thinking Erikson: Identity versus Role Diffusion Mahler: Separation – Individuation The brain is far from mature until ages 20 – 25 !

Brain Development Facts
At six months gestation, maximum brain density is reached During final trimester, dramatic pruning occurs to eliminate unnecessary cells At birth, baby has almost all of neurons By age 6, child has 90 – 95% of adult brain size

Developmental Neuroanatomy
From birth through 18 months: Neurons attempt massive connection strategy Grey matter volume expands Infants learn like ‘sponges absorb water’

The Second Wave It was originally thought that after age 2, the brain ‘ages’ Second wave of grey matter overproduction just prior to puberty Peaks around age 11 in girls, 12 in boys Due to sex hormones?

Adolescent Behavior Characteristics: Two Main Factors:
Emotional Outbursts Reckless Risk Taking Rule Breaking Sex, Drugs and Rock ‘n Roll Raging Hormones Lack of Brain Development (mature, cognitive controls)

Brain Development Facts (cont.)
Caution: Construction Ahead! First Wave of Pruning - Prenatal Alters the number of neurons Second Wave of Pruning - Adolescence Alters the number of connections (synapses) between neurons Affects highest mental functions

White Matter Growth White matter steadily continues from birth until early 20’s even as grey matter growth subsides Frontal lobes are last area to fully mature

Substance Abuse and Brain Development
Dopamine is abundant and active in the adolescent brain Rapid changes in dopamine receptors in midbrain project to nucleus accumbens Nucleus accumbens is somewhat immature, but more mature than the rest of the frontal lobes Directs motivation to seek rewards Involved in drug reinforcement and reward Gene + Environment + Brain Development (so it’s not just peer pressure)

Gray Matter Peaks Girls age 11 Boys age 12 ½ Thins at rate of 0.7% per year until the early 20s White Matter Myelin sheaths (insulation) Thickens until around age 40

The Neuron

Final result of myelination and pruning ( ↓ arborization) Fewer, but faster, connections More efficient machine Trade off Loses some of the raw potential for learning and the ability to recover from trauma

Construction Anatomy Brain Development:
Proliferation and pruning occurs from back to front Back: Region that mediates direct contact with environment Next: Regions that coordinate those functions Last: Prefrontal Cortex

Construction Anatomy (cont.)
Cerebellum Physical Coordination More sensitive to environment than heredity Supports higher learning activities Mathematics Music Advanced Social Skills This is the only part of the brain that keeps growing well into your 20’s

Basal Ganglia Secretary to the Prefrontal Cortex Prioritizes information Tightly connected to Prefrontal Cortex Almost simultaneously growing and pruning Active in small and large motor movements Preteen exposure to music and sports is important

Amygdala Emotional center Primal fear – rage ‘Gut’ reactions Processes most of the emotional information in teens* *Adults depend more on the Prefrontal Cortex (which is not yet fully developed in teens)

Nucleus Accumbens Deep in the mid-brain The “Reward Center” associated with drug intoxication (the “high”) and drug withdrawal Pineal Gland At base of the brain Produces melatonin

Prefrontal Cortex The CEO – handles the “Executive Functions” Area of sober second thoughts Last part of brain to mature Grows during preteen years Shrinks during teen ‘pruning’ for more efficient connections

Prefrontal Cortex “Executive Functions” Planning Setting Priorities Organizing Thoughts Suppressing Impulses Weighing Consequences Take-Home Message: The final part of the brain to ‘grow up’ is the part capable of deciding to finish homework and take out the trash before calling friends.

Cartoon Break

Right Lateral and Top Views of the Dynamic Sequence of GM Maturation Over the Cortical Surface
Source: Gogtay, Nitin et al (2004) Proc. Natl. Acad. Sci. USA 101; Copyright 2004 by the National Academy of Sciences

Exposure to drugs of abuse during adolescence could have profound effects on Brain Development and Brain Plasticity Understanding drug abuse and addiction from a developmental perspective has important implications for their prevention and treatment

Motivation And the Impact of Brain Development Nucleus Accumbens
Dopamine – main neurotransmitter in the Nucleus Accumbens Involved in motivation as well as in reinforcing behavior Nucleus Accumbens Located deep in the brain Operates far below the conscious cortex In its interactions with the amygdala, it directs motivation to seek rewards Consequences: Immediate + Tangible

New Understandings about Addiction
Addiction is a disease of the brain Dopamine in the VTA and the Nucleus Accumbens is important in Drug Reward (the ‘Reward Pathway’ of the MFB etc.) BUT we now understand that the Nuc Acc is where REWARD HAPPENS, whereas ADDICTION resides in the OFC and in connections among the Nuc Acc, the OFC, the hippocampus and the amygdala

Slide 11: The reward pathway
Tell your audience that this is a view of the brain cut down the middle. An important part of the reward pathway is shown and the major structures are highlighted: the ventral tegmental area (VTA), the nucleus accumbens and the prefrontal cortex. The VTA is connected to both the nucleus accumbens and the prefrontal cortex via this pathway and it sends information to these structures via its neurons. The neurons of the VTA contain the neurotransmitter dopamine which is released in the nucleus accumbens and in the prefrontal cortex (point to each of these structures). Reiterate that this pathway is activated by a rewarding stimulus. [Note: the pathway shown here is not the only pathway activated by rewards, other structures are involved too, but only this part of the pathway is shown for simplicity.]

Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC) and in connections between OFC et al.
Addiction is use despite adverse consequences, returning to use after periods of abstinence even with previous life catastrophes, inability to control use, cognitive preoccupation, conscious and unconscious craving It involves memory, judgment, ‘executive functions’ of planning and deciding to defer gratification All these are Frontal Lobe functions

Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC) and in connections between OFC et al.

MEMORY/ LEARNING CONTROL REWARD MOTIVATION/ DRIVE
Circuits Involved in Drug Abuse and Addiction PFC MEMORY/ LEARNING CONTROL INHIBITORY ACG Hipp OFC SCC NAcc VP REWARD Amyg MOTIVATION/ DRIVE

Addiction ‘resides’ somewhat in the Orbitofrontal Cortex (OFC) and in other areas with connections to Reward Circuitry The site of acute action for euphoriants is the nucleus accumbens (an oversimplification) The site of action for the chronic, recurrent, relapsing exposure to euphoriants--as is see in addiction—is the interplay among the Nuc Acc, the hippocampus (memory; recalling past experiences), the amygdala (motivation, drive, drug hunger/craving; drug seeking/use), and the frontal lobes (judgment/evaluation, planning, delay of gratification, inhibition of urges/impulses)

GO STOP Non Addicted Brain Addicted Brain Drive Saliency Memory
Control Drive Saliency Memory Non Addicted Brain Addicted Brain Control Saliency Memory Drive STOP GO

The Physiology of Addiction
Certain substances have the ability to interact with the brain’s Reward Circuitry and are thus euphoriants; they are reinforcing, and, in lab animals, self-reinforcing. They act first by being external ligands for neuro-transmitter receptors, or by causing release of (or otherwise altering levels of) neuro-transmitters. They hijack the reward system, and the individual compulsively pursues these rewards instead of natural rewards.

Once the Reward Circuitry is turned on, there are changes in related brain areas or neuronal circuits, and these result in the characteristic manifestations of addiction [altered memory of past intoxication experiences, altered cue response, changes in motivation so that ‘the drug’ (can be a substance, or a pathologically rewarding activity) becomes ‘the salient reinforcer,’ replacing other healthy reward]. All this contributes to preoccupation and loss of control. The most contemporary term for all this circuitry is the brain’s “incentive salience circuitry.”

Changes in frontal lobe function (executive functioning; the inhibition of impulses to use) are key: the brain fails in efforts to inhibit the drive to obtain/use the drug to create ‘the high’. Impairment in control and preoccupation are the key behavioral/cognitive characteristics of addiction, and have an anatomical/physiological substrate in the brain. Relapse is intrinsic to virtually all chronic diseases; the animal model of relapse is “reinstatement” of drug use or drug preference.

West Coast Symposium on Addictive Disorders (WCSAD) June 1, 2012
The ASAM Definition of Addiction: The Pathological Pursuit of Reward or Relief West Coast Symposium on Addictive Disorders (WCSAD) June 1, 2012

Addiction is not… Just a social problem Just a criminal problem
Just a moral problem Frequent intoxication, heavy use, having fun High frequency / high quantity use Physical Dependence

Addiction is… A BRAIN DISEASE
A primary, relapsing and remitting CHRONIC DISEASE…. A PEDIATRIC DISEASE….

Addiction is a Developmental Disease
1.8 TOBACCO THC 1.6 ALCOHOL 1.4 1.2 % in each age to develop first-time dependence 1.0 0.8 0.6 0.4 Most new cases of drug dependence develop during adolescence. Perhaps there is something special (“sensitive”) about adolescence for developing addiction. 0.2 0.0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 Age Age at tobacco, at alcohol and at cannabis dependence, as per DSM IV National Epidemiologic Survey on Alcohol and Related Conditions, 2003

How is it that DRUGS are different from broccoli?
It’s because of what ‘drugs’ do to the BRAIN Drugs enter the body via various routes Oral, Intravenous, Intramuscular, Intranasal, transdermal, transbuccal, or transalveolar Drugs that affect mood/thought/behavior cross the ‘blood brain barrier’ Drugs act on nerve cells by binding to specialized portions of the outer membrane of nerve cells

MEMORY/ LEARNING CONTROL REWARD MOTIVATION/ DRIVE
Circuits Involved in Drug Abuse and Addiction PFC MEMORY/ LEARNING CONTROL INHIBITORY ACG Hipp OFC SCC NAcc VP REWARD Amyg MOTIVATION/ DRIVE

What is Addiction? American Society of Addiction Medicine • April 2011
Definition of Addiction: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

Definition of Addiction American Society of Addiction Medicine • April 2011
“Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

Upward Progression of Illness: Downward Spiral
Addiction & Trauma (constriction) Recovery & Healing (expansion) Copyright (c)2011, Covington, Griffin, & Dauer

Atrophy Of social network Of activities / interests Of emotions
People… Of activities / interests Places, Things Of emotions Flatness, less expressive, dysthymic / alexithymic Of rewards Salience

Upward Narrowing / Atrophy of Interests Activities / Rewards
Addiction & Trauma (constriction) Recovery & Healing (expansion) Copyright (c)2011, Covington, Griffin, & Dauer

How to come out of the depths? How to RECOVER?
Re-people-ization AA Sponsor Church Social clubs Activities with others Family Professional Treatment (group therapy, meet others) Re-Connectedness

ASAM Public Policy Statement: Definition of Addiction (Long Version)
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors.

ASAM Public Policy Statement: Definition of Addiction (Long Version)
Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.

The neurobiology of addiction encompasses more than the neurochemistry of reward.1
The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation and memory are fundamental in the manifestations of altered impulse control, [and] altered judgment….

…and the dysfunctional pursuit of rewards (which is often experienced by the affected person as a desire to “be normal”) seen in addiction--despite cumulative adverse consequences experienced from engagement in substance use and other addictive behaviors.

The frontal lobes are important in inhibiting impulsivity and in assisting individuals to appropriately delay gratification. When persons with addiction manifest problems in deferring gratification, there is a neurological locus of these problems in the frontal cortex.

Frontal lobe morphology, connectivity and functioning are still in the process of maturation during adolescence and young adulthood, and early exposure to substance use is another significant factor in the development of addiction. Many neuroscientists believe that developmental morphology is the basis that makes early-life exposure to substances such an important factor.

Footnote 1: The neurobiology of reward has been well understood for decades, whereas the neurobiology of addiction is still being explored. Most clinicians have learned of reward pathways including projections from the ventral tegmental area (VTA) of the brain, through the median forebrain bundle (MFB), and terminating in the nucleus accumbens (Nuc Acc), in which dopamine neurons are prominent. Current neuroscience recognizes that the neurocircuitry of reward also involves a rich bi-directional circuitry connecting the nucleus accumbens and the basal forebrain.

Footnote 1 (continued): It is the reward circuitry where reward is registered, and where the most fundamental rewards such as food, hydration, sex, and nurturing exert a strong and life-sustaining influence. Alcohol, nicotine, other drugs and pathological gambling behaviors exert their initial effects by acting on the same reward circuitry that appears in the brain to make food and sex, for example, profoundly reinforcing. Other effects, such as intoxication and emotional euphoria from rewards, derive from activation of the reward circuitry.

Footnote 1 (continued): While intoxication and withdrawal are well understood through the study of reward circuitry, understanding of addiction requires understanding of a broader network of neural connections involving forebrain as well as midbrain structures. Selection of certain rewards, preoccupation with certain rewards, response to triggers to pursue certain rewards, and motivational drives to use alcohol and other drugs and/or pathologically seek other rewards, involve multiple brain regions outside of reward neurocircuitry itself.

Naqvi NH, Bechara A Trends in Neurosciences, 32:56-67, 2008
“Although the dopamine system clearly has an important role in addiction to drugs of abuse, drug use does more for the addicted individual than merely providing a means of releasing dopamine in the brain. Drug use involves a complex set of rituals imbued with emotional meaning (both positive and negative) for the addicted individual.”

Genetic factors account for about half of the likelihood that an individual will develop addiction.
Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence. Resiliencies the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavioral and other manifestations of addiction. Culture also plays a role in how addiction becomes actualized in persons with biological vulnerabilities to the development of addiction.

Environmental / Cultural Factors
Availability Social Norms for/against Indoor smoking bans MADD “Those Who Host Lose the Most” Perceived Harm Consequences (legal status; drug-free schools) “Peer Pressure” Siblings Parents Their Use Their Attitudes (perceived harm) Their Rules/Consequences (parents are ‘the antidrug’)

Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include: The presence of an underlying biological deficit in the function of reward circuits, such that drugs and behaviors which enhance reward function are preferred and sought as reinforcers; The repeated engagement in drug use or other addictive behaviors, causing neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors; Cognitive and affective distortions, which impair perceptions and compromise the ability to deal with feelings, resulting in significant self-deception;

“…neuroadaptation in motivational circuitry leading to impaired control over further drug use or engagement in addictive behaviors….” [O’Brien: “addiction = neuroplasticity”] changes in motivation/control changes in cue responsiveness [See also: Koob GF, Volkow ND. “Neurocircuitry of addiction.” Neuropsychopharmacology Jan;35(1): ]

Other factors that can contribute to the appearance of addiction, leading to its characteristic bio-psycho-socio-spiritual manifestations, include: Disruption of healthy social supports and problems in interpersonal relationships which impact the development or impact of resiliencies; Exposure to trauma or stressors that overwhelm an individual’s coping abilities; Distortion in meaning, purpose and values that guide attitudes, thinking and behavior; Distortions in a person’s connection with self, with others and with the transcendent (referred to as God by many, the Higher Power by 12-steps groups, or higher consciousness by others); and The presence of co-occurring psychiatric disorders in persons who engage in substance use or other addictive behaviors.

Addiction is characterized by2:
Inability to consistently Abstain; Impairment in Behavioral control; Craving; or increased “hunger” for drugs or rewarding experiences; Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and A dysfunctional Emotional response.

Naqvi NH, Bechara A Trends in Neurosciences, 32:56-67, 2008
“…Studies using animal models [which] have emphasized the role of subcortical systems such as the amygdala, nucleus accumbens and the mesolimbic dopamine system…have tended to focused on externally observable aspects of addiction (emphasis added)”

The power of external cues to trigger craving and drug use,
…as well as to increase the frequency of engagement in other potentially addictive behaviors, is also a characteristic of addiction, with the hippocampus being important in memory of previous euphoric or dysphoric experiences, and with the amygdala being important in having motivation concentrate on selecting behaviors associated with these past experiences.

Although some believe that the difference between those who have addiction, and those who do not, is the quantity or frequency of alcohol/drug use, engagement in addictive behaviors (such as gambling or spending) 3, or exposure to other external rewards (such as food or sex)…,

…a characteristic aspect of addiction is the qualitative way in which the individual responds to such exposures, stressors and environmental cues. A particularly pathological aspect of the way that persons with addiction pursue substance use or external rewards is that preoccupation with, obsession with and/or pursuit of rewards (e.g., alcohol, nicotine and other drug use) persist despite the accumulation of adverse consequences. These manifestations can occur compulsively or impulsively, as a reflection of impaired control.

“The subcommittee has distinguished two categories of alcoholics, “alcohol addicts” and “habitual symptomatic excessive drinkers. For brevity’s sake the latter will be referred to as non-addictive alcoholics. In both groups, the excessive drinking is symptomatic of underlying psychological or social pathology….” WHO Technical Report Series No. 48, August 1952, pp

“…but in one group after several years of excessive drinking “loss of control” over the alcohol intake occurs, while in the other group this phenomenon never develops. The group with “loss of control” is designated as “alcohol addicts.” WHO Technical Report Series No. 48, August 1952, pp 26-27

“The disease conception of alcohol addiction does not apply to the excessive drinking, but solely to the ‘loss of control’ which occurs in only one group of alcoholics and then only after many years of excessive drinking.” WHO Technical Report Series No. 48, August 1952, pg 27

“The ‘loss of control’ is a disease condition per se which results from a process that superimposes itself upon those abnormal psychological conditions of which excessive drinking is a symptom. The fact that many excessive drinkers drink as much as or more than the addict for 30 or 40 years without developing loss of control indicates that in the group of ‘alcohol addicts’ a superimposed process must occur.” WHO Technical Report Series No. 48, August 1952, pg 27

Griffith Edwards (1976) “…Awareness of ‘loss of control’ is said to be crucial to understanding abnormal drinking…. “Control is probably best seen as variably and intermittently impaired rather than ‘lost’.”

Although some believe that the difference between those who have addiction, and those who do not, is the quantity or frequency of alcohol/drug use, engagement in addictive behaviors (such as gambling or spending) 3, or exposure to other external rewards (such as food or sex)…,

Persistent risk and/or recurrence of relapse, after periods of abstinence, is another fundamental feature of addiction. This can be triggered by exposure to rewarding substances and behaviors, by exposure to environmental cues to use, and by exposure to emotional stressors that trigger heightened activity in brain stress circuits.4

Footnote 4: The anatomy (the brain circuitry involved) and the physiology (the neuro-transmitters involved) in these three modes of relapse (drug- or reward-triggered relapse vs. cue-triggered relapse vs. stress-triggered relapse) have been delineated through neuroscience research.

Relapse triggered by exposure to addictive/ rewarding drugs, including alcohol, involves the nucleus accumbens and the VTA-MFB-Nuc Acc neural axis (the brain's mesolimbic dopaminergic "incentive salience circuitry"--see Footnote 2 above). Reward-triggered relapse also is mediated by glutamatergic circuits projecting to the nucleus accumbens from the frontal cortex.

Relapse triggered by exposure to conditioned cues from the environment involves glutamate circuits originating in frontal cortex, insula, hippocampus and amygdala projecting to mesolimbic incentive salience circuitry.

Relapse triggered by exposure to stressful experiences involves brain stress circuits beyond the hypothalamic-pituitary-adrenal axis that is well known as the core of the endocrine stress system. There are two of these relapse-triggering brain stress circuits – one originates in noradrenergic nucleus A2 in the lateral tegmental area of the brain stem and projects to the hypothalamus, nucleus accumbens, frontal cortex, and bed nucleus of the stria terminalis, and uses norepinephrine as its neurotransmitter; the other originates in the central nucleus of the amygdala, projects to the bed nucleus of the stria terminalis and uses corticotrophin-releasing factor (CRF) as its neurotransmitter.

“Relapse” or “Reinstatement” Griffith Edwards (1976)
“Relapse into the previous stage of the dependence syndrome…follows an extremely variable time course. Typically, the patient who had only a moderate degree of dependence will take weeks or months to reinstate it….”

“A severely dependent patient typically reports that he is again ‘hooked’ within a few days of starting to drink, even though there are exceptions: on the first day he may become abnormally drunk and be surprised to have lost his tolerance.”

“A syndrome which had taken many years to develop can be fully reinstated within perhaps 72 hours, and this is one of the most puzzling features of the condition.” [kindling]

In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications.

The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol, nicotine or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the correlation with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of Twelve Step programs.

Addiction is more than a behavioral disorder.
Features of addiction include aspects of a person’s behaviors, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.

Behavioral manifestations and complications of addiction, primarily due to impaired control, can include: Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control; Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work);

Behavioral manifestations and complications of addiction, primarily due to impaired control, can include: Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviors; A narrowing of the behavioral repertoire focusing on rewards that are part of addiction; and An apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems.

Cognitive changes in addiction can include:
Preoccupation with substance use; Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviors; and The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.

Emotional changes in addiction can include:
Increased anxiety, dysphoria and emotional pain; Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).

Memory and Learning (not in the ASAM Definition)
Memory and learning in addiction involves more than recall of previous positive experiences with alcohol, tobacco or other drug use or other exposures to rewards, and more than repression or distortion of memories of the negative experiences associated with pursing or exposing oneself to rewards. It also involves more than the cognitive and emotional aspects of conscious and unconscious craving and the conditioning, through recollection of previous experiences with learned triggers, to re-engage with the pathological pursuit of rewards.

Memory in addiction also has a behavioral and motor component, which seems to be mediated by the rostral (anterior) portion of the ventral tegmental area: certain motor behaviors associated with pursing rewards, e.g., going out and finding supplies of drugs, or food, or gambling materials, may be recalled or ingrained in circuitry of the rostral VTA, such that those motor behaviors have been “learned” and reappear in the behavioral repertoire of the person with addiction without there being a conscious component to the behavior’s reoccurrence.

Complex motor behaviors such as reaching for both cigarettes and ignition materials and “lighting up”—or even getting into an automobile and driving to a liquor store—may occur based on unconscious patterns of learned motor or kinesthetic behavior in addition to the emotional or physiological drive to experience a drug effect or another reward. --Michael M. Miller, M.D.

The emotional aspects of addiction are quite complex.
Some persons use alcohol or other drugs or pathologically pursue other rewards because they are seeking “positive reinforcement” or the creation of a positive emotional state (“euphoria”). Others pursue substance use or other rewards because they have experienced relief from negative emotional states (“dysphoria”), which constitutes “negative reinforcement.“ Beyond the initial experiences of reward and relief, there is a dysfunctional emotional state present in most cases of addiction that is associated with the persistence of engagement with addictive behaviors.

The state of addiction is not the same as the state of intoxication.
When anyone experiences mild intoxication through the use of alcohol or other drugs, or when one engages non-pathologically in potentially addictive behaviors such as gambling or eating, one may experience a “high”, felt as a “positive” emotional state associated with increased dopamine and opioid peptide activity in reward circuits. After such an experience, there is a neurochemical rebound, in which the reward function does not simply revert to baseline, but often drops below the original levels. This is usually not consciously perceptible by the individual and is not necessarily associated with functional impairments.

Over time, repeated experiences with substance use or addictive behaviors are not associated with ever increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviors, there is an anxious, agitated, dysphoric and labile emotional experience, related to suboptimal reward and the recruitment of brain and hormonal stress systems, which is associated with withdrawal from virtually all pharmacological classes of addictive drugs.

While tolerance develops to the “high,” tolerance does not develop to the emotional “low” associated with the cycle of intoxication and withdrawal. Thus, in addiction, persons repeatedly attempt to create a “high”--but what they mostly experience is a deeper and deeper “low.” While anyone may “want” to get “high”, those with addiction feel a “need” to use the addictive substance or engage in the addictive behavior in order to try to resolve their dysphoric emotional state or their physiological symptoms of withdrawal.

Persons with addiction compulsively use even though it may not make them feel good, in some cases long after the pursuit of “rewards” is not actually pleasurable.5 Although people from any culture may choose to “get high” from one or another activity, it is important to appreciate that addiction is not solely a function of choice. Simply put, addiction is not a desired condition.

The Absinthe Drinker, Edward Degas

Griffith Edwards (1976) “Without withdrawing sympathy from the non-dependent drinker who is experiencing harm, society should be asked to realize that the person who has become dependent on alcohol is certainly ill; and the possibility of contracting this illness awaits anyone who drinks very heavily.”

As addiction is a chronic disease, periods of relapse, which may interrupt spans of remission, are a common feature of addiction. It is also important to recognize that return to drug use or pathological pursuit of rewards is not inevitable.

Clinical interventions can be quite effective in altering the course of addiction. Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. Engagement in health promotion activities which promote personal responsibility and accountability, connection with others, and personal growth also contribute to recovery. It is important to recognize that addiction can cause disability or premature death, especially when left untreated or treated inadequately.

The qualitative ways in which the brain and behavior respond to drug exposure and engagement in addictive behaviors are different at later stages of addiction than in earlier stages, indicating progression, which may not be overtly apparent.

Griffith Edwards (1976) on progression
“The model need not, of course, propose a rigidly stereotyped progression. “…Milder degrees can indeed regress and the patient can return to normal drinking.” [Vaillant 1980, The Natural History of Alcoholism: 11% of alcoholics return to controlled drinking]

Griffith Edwards (1976) on progression
“A patient with an intermediate degree of dependence is, if he continues to drink, much more likely to progress to severe dependence than to move backwards down the curve. “Very severe dependence is usually irreversible, and if the patient will not accept abstinence he will repeatedly reinstate the syndrome.”

As is the case with other chronic diseases, the condition must be monitored and managed over time to: Decrease the frequency and intensity of relapses; Sustain periods of remission; and Optimize the person’s level of functioning during periods of remission.

In some cases of addiction, medication management can improve treatment outcomes.
In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results. Chronic disease management is important for minimization of episodes of relapse and their impact. Treatment of addiction saves lives †

BEHAVIORAL CHANGES BIOLOGICAL CHANGES Eliminate alcohol and other drug use behaviors Eliminate other problematic behaviors Expand repertoire of healthy behaviors Develop alternative behaviors Resolve acute alcohol and other drug withdrawal symptoms Physically stabilize the organism Develop sense of personal responsibility for wellness Initiate health promotion activities (e.g., diet, exercise, safe sex, sober sex

COGNITIVE CHANGES AFFECTIVE CHANGES Increase awareness of illness Increase awareness of negative consequences of use Increase awareness of addictive disease in self Decrease denial Increase emotional awareness of negative consequences of use Increase ability to tolerate feelings without defenses Manage anxiety and depression Manage shame and guilt

SOCIAL CHANGES SPIRITUAL CHANGES Increase personal responsibility in all areas of life Increase reliability and trustworthiness Become resocialized: reestablished sober social network Increase social coping skills: with spouse/partner, with colleagues, with neighbors, with strangers Increase self-love/esteem; decrease self-loathing Reestablish personal values Enhance connectedness Increase appreciation of transcendence Miller, Michael M. Principles of Addiction Medicine, 1994; published by American Society of Addiction Medicine, Chevy Chase, MD

Violating your own values, then re-establishing your values, matters.
Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. Q: Why is ASAM, as a medical organization, talking about “spirituality”? Answer: Because the members of the DDTAG, and of the BOD, recognize the multidimensional aspect of both the disease and of recovery Values matter Violating your own values, then re-establishing your values, matters. Connectedness matters. Meaning in life matters. Recovery is many things, including a search for meaning.

Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction.

As in other health conditions, self-management, with mutual support, is very important in recovery from addiction. Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery. ‡

Recovery from addiction is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.

Griffith Edwards (1976) “Doctors should be aware that not every patient who drinks too much (for whatever reason) is necessarily dependent on alcohol, and different patients need different help and treatment.”

NIDA Principles of Drug Addiction Treatment (1999, rev 2009)
1. Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased. 2. No single treatment is appropriate for everyone. NIH Publication No. 09–4180

So, to pull it all together….

Certain substances have the ability to interact with the brain’s Reward Circuitry and are thus euphoriants; they are reinforcing, and, in lab animals, self-reinforcing. They act first by being external ligands for neuro-transmitter receptors, or by causing release of (or otherwise altering levels of) neuro-transmitters. They hijack the reward system, and the individual compulsively pursues these rewards instead of natural rewards.

The Physiology of Intoxication
This is actually quite complex. The motor components of alcohol/sedative intoxication are manifestations of actions on the cerebellum and other motor control systems. The reward components of drug-induced euphoria vary somewhat from drug to drug: the nucleus accumbens is the major locus for cocaine, the central nucleus of the amygdala more so for alcohol.

The Physiology of Withdrawal
The physiological components of withdrawal are often autonomic: changes in pulse, blood pressure, temperature, and motor components including tremor. The rebound from the experience of emotional reward involves decreases in activity of reward systems in the nucleus accumbens and central nucleus of the amygdala, but also the recruitment of brain stress systems in the central nucleus of the amygdala and bed nucleus of the stria terminalis.

Once the Reward Circuitry is turned on, there are changes in related brain areas or neuronal circuits, and these result in the characteristic manifestations of addiction [altered memory of past intoxication experiences, altered cue response, changes in motivation so that ‘the drug’ (can be a substance, or a pathologically rewarding activity) becomes ‘the salient reinforcer,’ replacing other healthy reward]. All this contributes to preoccupation and loss of control. The most contemporary term for all this circuitry is the brain’s “incentive salience circuitry.”

Changes in frontal lobe function (executive functioning; the inhibition of impulses to use) are key: the brain fails in efforts to inhibit the drive to obtain/use the drug to create ‘the high’. Impairment in control and preoccupation are the key behavioral/cognitive characteristics of addiction, and have an anatomical/physiological substrate in the brain. Relapse is intrinsic to virtually all chronic diseases; the animal model of relapse is “reinstatement” of drug use or drug preference.

“Addiction: Then and Now”

Similar presentations

Presentation on theme: "“Addiction: Then and Now”"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

“Addiction: Then and Now”

Similar presentations

Presentation on theme: "“Addiction: Then and Now”"— Presentation transcript:

Similar presentations

About project

Feedback