!!!!!!

Title& !

Below&please&list&the&title&of&this&resource.&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

Addiction!Recovery!Management!

! Author&
Below&please&list&the&author(s)&of&this&resource."

Kevin!McCauley,!MD!

! Citation& !

Below&please&cite&this&resource&in&APA&style.&For&guidance&on&citation&format,&please&visit& http://owl.english.purdue.edu/owl/resource/560/01/&

McCauley!MD,!Kevin.!(2011).!Addiction"Recovery"Management![PowerPoint!slides].!Retrieved!from! www.instituteforaddictionstudy.com!!

! Summary&
Below&please&provide&a&brief&summary&of&this&resource.&If&an&abstract&is&available,&feel&free&to&copy&and&paste&it&here.&

This!power!point!presentation!highlights!how!the!disease!of!addiction!works!and!the!brain!functions!and! reactions!that!accompany!the!disease.!The!slides!go!on!to!explore!the!five!theories!of!addiction.!He!then! reviews!methods!of!treatment!followed!by!an!exploration!of!recovery!capital,!recovery!management,! recovery!resource!mapping,!and!recovery:oriented!systems!of!care.!

Categorization&
Below,&please&select&the&key&words&that&describe&how&this&resource&applies&to&our&research&on&thriving&collegiate& recovery.&If&the&keywords&below&do&not&apply,&please&select&other&and&list&the&appropriate&key&word.& " "Success"in"Established"Collegiate"Recovery"Programs" "Success"in"Established"Recovery<Oriented"Systems"of"Care" X"Asset<Based"Research/Methodology" X"General"Recovery"Assets" "Interpersonal"Assets" "Intrapersonal"Assets" "Community<Based"Assets" "History"of"Recovery" "Other:"______________________________________"

!!!!!!!!!!!!!!!!!!!!!!!!!!P.!O.!Box!6448!!Reno,!NV!89513!!Phone:!760:815:[email protected]! !

!!!!!!

Title& !

Below&please&list&the&title&of&this&resource.&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

Addiction!Recovery!Management!

! Author&
Below&please&list&the&author(s)&of&this&resource."

Kevin!McCauley,!MD!

! Citation& !

Below&please&cite&this&resource&in&APA&style.&For&guidance&on&citation&format,&please&visit& http://owl.english.purdue.edu/owl/resource/560/01/&

McCauley!MD,!Kevin.!(2011).!Addiction"Recovery"Management![PowerPoint!slides].!Retrieved!from! www.instituteforaddictionstudy.com!!

! Summary&
Below&please&provide&a&brief&summary&of&this&resource.&If&an&abstract&is&available,&feel&free&to&copy&and&paste&it&here.&

! This!power!point!presentation!highlights!how!the!disease!of!addiction!works!and!the!brain! functions!and!reactions!that!accompany!the!disease.!The!slides!go!on!to!explore!the!five! theories!of!addiction.!He!then!reviews!methods!of!treatment!followed!by!an!exploration!of! recovery!capital,!recovery!management,!recovery!resource!mapping,!and!recovery: oriented!systems!of!care.! Categorization&

Below,&please&select&the&key&words&that&describe&how&this&resource&applies&to&our&research&on&thriving&collegiate& recovery.&If&the&keywords&below&do&not&apply,&please&select&other&and&list&the&appropriate&key&word.& " "Success"in"Established"Collegiate"Recovery"Programs" "Success"in"Established"Recovery<Oriented"Systems"of"Care" X"Asset<Based"Research/Methodology" X"General"Recovery"Assets" "Interpersonal"Assets" "Intrapersonal"Assets" "Community<Based"Assets" "History"of"Recovery" "Other:"______________________________________"

!!!!!!!!!!!!!!!!!!!!!!!!!!P.!O.!Box!6448!!Reno,!NV!89513!!Phone:!760:815:[email protected]! !

Addiction Recovery Management!

The Institute for Addiction Study! Salt Lake City, Utah! www.instituteforaddictionstudy.com!

Kevin T. McCauley, M.D.!

[email protected]
(435) 659-6293

The most evil disease imaginable

Wouldn t look like a disease at all (nearly invisible epidemiologically) Genetic, but with variable penetrance (genotype phenotype) Repulsive symptoms easily confused with willful badness Self-deception as a clinical feature Poor prognosis if untreated, but some will get better (inexplicably) Chronic and relapsing (not acute, nor cured) Culturally & politically divisive (would tap into society s deepest prejudices, stigma, superstitions and attack its core values) Maximally economically destructive (solutions based on greed & exploitation) Would cover its tracks (by blaming other diseases) Would only submit to weird solutions: peer support, patient accountability, personal evaluation, and spiritual growth (not just a medication or surgery)

The Key Parts of the Limbic Brain

Orbitofrontal Cortex (OFC)

Decision-making guided by rewards Integrates sensory and emotional information from lower limbic structures Flexible assignment of value to environmental stimuli to motivate or inhibit choices & actions Self-monitoring and social responding

Anterior Cingulate Cortex (ACC)

Works with OFC: decision-making based on reward values But also generates new actions based on past rewards/punishments Appreciation and valuation of social cues MRI: active in tasks requiring empathy and trust

Prefrontal Cortex (PFC)

Behavioral regulation Reective decisionmaking Inhibition of socially inappropriate actions Emotional and sensory integration Planning complex behaviors Personality expression

But drugs don t work in the! Frontal Cortex . . .

Drugs work rst in the Midbrain

The Midbrain is the SURVIVAL brain

Not conscious Acts immediately, no future planning or assessment of long-term consequences A life-or-death processing station for arriving sensory information

In addiction, the drug hijacks the survival hierarchy and is so close to actual survival that it is indistinguishable from actual survival

New #1: DRUG!

2. EAT! 3. KILL! 4. SEX !

Addiction is a disorder in the brain s Reward (Hedonic) System

It is a broken pleasure sense in the brain

Addiction is a disorder of
5. CHOICE 4. STRESS 3. MEMORY 2. REWARD 1. GENES (motivation) (anti-reward system) (learning) (hedonic system) (vulnerability)

Five Theories of Addiction

1. Genetic Vulnerability (Schuckit et al) 2. Incentive-sensitization of Reward (Robinson & Berridge) 3. Pathology of Learning & Memory (Hyman, Everitt & Robbins) 4. Stress and Allostasis (Koob & LeMoal) 5. Pathology of Motivation and Choice (Kalivas & Volkow)

Addiction Neurochemical #1: Dopamine

All drugs of abuse and potential compulsive behaviors release Dopamine Dopamine is rst chemical of a pleasurable experience - at the heart of all reinforcing experiences DA is the neurochemical of salience (it signals survival importance) DA signals reward prediction error Tells the brain this is better than expected

Incentive-Sensitization (Robinson & Berridge)

Distinguished between a liking and a wanting role for Dopamine (it s more about wanting ) Created hyper-dopaminergic Dopamine Transporter knock-down mice (mice with increased synaptic Dopamine) Observed increased intake of reinforcing substances in these mice and greater thwarting of obstacles to get them (i.e. more wanting ) But did not observe greater liking of these substances by these mice

Drugs cause Dopamine Surges in the midbrain reward system

The Full Spectrum of Addiction

Alcohol & Sedative/Hypnotics Opiates/Opioids Cocaine Amphetamines Entactogens (MDMA) Entheogens/Hallucinogens Dissociants (PCP, Ketamine) Cannabinoids Inhalants Nicotine Caffeine Anabolic-Androgenic Steroids
Food (Bulimia & Binge Eating) Sex Relationships Other People ( Codependency, Control) Gambling Cults Performance ( Work-aholism ) Collection/Accumulation ( Shop-aholism ) Rage/Violence Media/Entertainment

Addiction Neurochemical #2: Glutamate

The most abundant neurochemical in the brain Critical in memory formation & consolidation All drugs of abuse and many addicting behaviors effect Glutamate which preserves drug memories and creates drug cues And glutamate is the neurochemical of motivation (it initiates drug seeking)

DOPAMINE (DA)
All drugs of abuse and potential compulsive behaviors INCREASE DA Reward salience this is important! I really want this! Rostral (toward the nose) projections: PFC < NA < VTA

GLUTAMATE (Glu)
All drugs of abuse and potential compulsive behaviors EFFECT Glu Drug memories Drug seeking OK, I ll remember Fine, go and get it Caudal (toward the tail) projections: PFC > NA

The hypofrontal/craving brain state represents and imbalance between 2 brain drives
Cortico-Striatal Circuit Amygdalar-Cortical Circuit

STOP!
Organized, Attentive Sensitive to consequences Well-planned Socially appropriate

GO!
Impulsive Non-reective Poorly conceived Socially inappropriate

THERE S TOO LITTLE OF THIS

THERE S TOO MUCH OF THIS

CHRONIC, SEVERE STRESS = CRF! and CRF = DAD2 receptors! and DAD2 receptors = Anhedonia ! Anhedonia: Pleasure deafness
(the patient is no longer able to derive normal pleasure from those things that have been pleasurable in the past)

Relapse
Three things that are known to evoke relapse in humans: 1. Brief exposure to drug itself (DA release) 2. Exposure to drug cues (GLU release) 3. Stress (CRF release)
(example of a dangerous relapse-triggering behavior: talking about drugs (cues) with other newly-sober addicts in treatment (stressed) while smoking (DA surge)

Craving / Drug Seeking

Not quite as conscious as deliberative acts More automatic - like driving a car home from work without really thinking about it I was vaguely aware that what I was doing was not too smart There I was again with a drink in my hand thinking that this time things would be different

damage to Orbitofrontal Cortex (OFC)

Causes a loss of a crucial behavioral guidance system Responses are impulsive and inappropriate Decits of self-regulation Inability to properly assign value to rewards (such as money vs. drugs) Tendency to choose small & immediate rewards over larger but delayed rewards

damage to Anterior Cingulate Cortex (ACC)

Just as with OFC damage: causes a loss of a crucial behavioral guidance system Inexibility/Inability to respond to errors in the past with regard to rewards/punishments Decits in social responding due to decreased awareness of social cues

damage to Prefrontal Cortex (PFC)

Failure of executive function

Hypofrontality
Bechara: research on pts with vmPFC & OFC lesions Myopia for the future - cognitive impulsiveness - these patients prefer immediate but disadvantageous rewards over rewards that are delayed but advantageous in the long run - their decisions are guided primarily by immediate prospects and are insensitive to positive or negative future consequences (rewards or punishments) - they deny or are unaware of their problem Scans of vmPFC patients are similar to Sub Abuse pts

Why the Choice Argument fails

It fails to take into account CRAVING The Choice Argument measures addiction only by the addict s external behavior It ignores the inner suffering of the patient You don t actually have to have drug use for the defective physiology of addiction to be active The addict cannot choose to not crave

So how DO we break the hold of craving and turn the Frontal Cortex back on ?

Addiction Part One:

misperception of the hedonic aspects of the drug And attribution of survival salience to the drug on the level of the unconscious

Addiction Part Two:

The drug takes on personal meaning The addict develops an emotional relationship with the drug The addict derives their sense of self and exerts agency through the drug

The Two Tasks of Addiction Treatment: 1. To give the addict workable, credible tools to proactively manage stress and decrease craving 2. For each individual addict, nd the thing which is more emotionally meaningful than the drug - and displace the drug with it

Addiction is a disorder of
6. MEANING (spirituality?) 5. CHOICE (motivation) 4. STRESS (anti-reward system) 3. MEMORY (learning) 2. PLEASURE (hedonic system) 1. GENES (vulnerability)

AA: using NON - Rational Concepts

TRIBE ( the fellowship of alcoholics ) MYTH (Bill s Story, etc.) RITUAL ( what it was like, what happened, and ) FAITH ( Keep coming back, it works ) HOPE (The Promises) ACCEPTANCE ( the answer to all my problems )

DSM-IV Criteria for Substance Dependence! (I M A TOWN DRUNK)

INABILITY (to cut down) MORE DRUG USED (than intended) A LOT OF TIME (spent obtaining, using & recovering from using the drug) TOLERANCE OLD ACTIVITIES, FRIENDS & FAMILY MEMBERS (given up in favor of the drug) WITHDRAWAL NEGATIVE CONSEQUENCES (have no effect on the pattern of drug use)

ASAM Addiction Denition (Aug 2011)

A primary, chronic and relapsing brain disease of reward (nucleus accumbens), memory (hippocampus & amygdala), motivation and related circuitry (ACC, basal forebrain) that alters motivational hierarchies such that addictive behaviors supplant healthy, self-care behaviors

If Addiction is a Disease, then

Addicts are patients! Addicts have the same rights as all patients All the ethical principles that apply to other patients now also apply to addicts

Addiction has parity

Addiction IS a Disease!
Everything treatment centers SAY is Addiction is a Disease But everything they DO shows that they don t really believe that themselves

What if we took ! punishment out of the treatment?

(Is there a group of addicts we don t punish?)

Things we do for pilots:

Medical Detoxication Inpatient or Residential Treatment Aftercare: Immediately after treatment for 3-5 Years A.A. Attendance Regular testing ( monitoring ) Return to duty Personal physician

Treatment Outcome Variance in Pilots Treated for Alcoholism:

The United States Navy enjoys a 95-97% return to ying status rate in its pilots treated for alcoholism. - Joseph A. Pursch, M.D. Since the inception of its impaired pilot program in conjunction with the FAA and ALPA EAPs, UAL has an 87% return to ight status rate in pilots treated for alcohol problems. - Stanley Mohler, M.D.

Problems with the Disease ( Acute Care ) Model

Reductive Materialistic Expensive, dramatic, late-stage, disruptive interventions in lieu of a more preventive Results in episodic, reactive, fragmented, poorly-targeted care Cannot address meaning, or spiritual/ community solutions Strips patient of power (and hands that power to the doctor) Encourages the sick role (fosters dependency, absolves responsibility)

Benets of inpatient care

Medical detoxication Baseline psychiatric evaluation & treatment Intensive daily structure Solidication of abstinence Removal from codependent family/social system Incapacitation of use Patient takes it seriously
Finney et al. Addiction 1996 91(12), 1773-1796

Chronic Diseases
Asthma Diabetes mellitus Kidney Disease Heart Disease/Post-MI Chronic Obstructive Pulmonary Disease (COPD) Hypertension Post-chemotherapy/Cancer Hepatitis B/C HIV/AIDS Major Depression Chronic Pain Lupus Erythematosis Cystic Fibrosis Alzheimers Disease Rheumatoid Arthritis Epilepsy Irritable Bowel Disease ADHD Addiction/Recovery Migrainosis Anticoagulation Therapy (post-DVT, Atrial Fibrillation)

advantages of a Chronic Care Model

Non-urgent More efcient and cost-effective Preventive Based on continuous, healing relationships Provides services across the continuum of care for life Centralized, local (no aircraft needed) Family-centered Informational (EMRs > NHII > research)

Disease Management
Disease Management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are signicant.

Goal: improving quality of life and reducing healthcare costs for individuals with chronic diseases by preventing or minimizing the effects of the disease through integrative care

Disease Management
Targets people with chronic conditions Located outside the point of care Personal communications (usually by telephone) Multidisciplinary team approach Linkage with community resources Patient education and self-management support Close monitoring of symptoms & reporting to clinical team Goal is to minimize or prevent complications, relapses, rehosp.

examples of Disease Management

Nurse outreach (telephony, home visits) Action planning, Symptom reporting Health coach advocacy, encouragement Remote home monitoring or daily testing Internet interfaces, questionnaires Physician practice support Risk assessment, stratication, targeting of intervention

What Disease Management looks like for

Diabetes
Daily Fasting Blood Glucose testing (and recording) Intensive ( Flexible ) Insulin therapy with MDI/pump Periodic Hemoglobin A1C testing to check long-term glycemic control Annual Ophthalmologic Exam Periodic Podiatric Exam/Foot Care Diet, Weight Control, Exercise Monitoring serum cholesterol and lipid prole Diabetes patient support groups

What Disease Management looks like for

Addiction
Community-based Sober Living/Residential Support Monitoring (non-random drug testing) Group Therapy/Cognitive-Behavioral Therapy Peer-Based Recovery Support Groups (AA, etc) Addictionologist/Addiction Psychiatrist Web-based Assessment Tools Call centers/Phone counseling Occupational/Vocational Assistance

Recovery Capital#
(Graneld & Cloud)

Recovery Capital is the sum total of all the personal, social, and community resources a person can draw on to begin and sustain their recovery from drug and alcohol problems.

Recovery Management
www.facesandvoicesofrecovery.org/ pdf/White/recovery_monograph_2008.pdf

Recovery-Oriented Systems of Care (ROSCs)

Recovery-Oriented Systems of Care (ROSCs)# support person-centered and self-directed approaches to care that build on the strengths and resilience of individuals, families, and communities to take responsibility for their sustained health, wellness and recovery from drug and alcohol problems.

Recovery Resource Mapping

Detox Facilities Inpatient Facilities Outpatient Programs Counselors Therapists Sober Coaches Addictionologists Testing Facilities Good 12-Step mtgs Jobs/Vocational Support Schools (CAADE!) Sober Homes

The Blueprint Studies

Dupont RL, McLellan AT, White WL, Carr G, Gendel M, Skipper GE. How are physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment 2009 Jul; 37(1): 1-7. Dupont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Setting the standard for recovery: physicians health programs. Journal of Substance Abuse Treatment 2009 Mar; 36(2): 159-71.

Characteristics of Physician Health Programs

Self-Reporting (safe harbor) or Workplace Referral Comprehensive Evaluation Signed Contract specifying in detail the elements of care and monitoring as well as consequences for non-compliance Inpatient Tx for 6090 days (69%) Intensive Outpatient Tx (31%) Agonist pharmacotherapy rare (but 1/3 received antidep/antianx Rx) Facilitated groups (Caduceus meetings) Return to work Drug testing (random call-in, approx. four times/month) Required participation in abstinencebased peer support groups (AA, NA, other) Monitoring for ve years, reporting to board of progress Family, colleague, employer involvement Rapid response to relapse, usually clinical reevaluation & intensication of care (but not administrative discharge)

Physician Health Programs (PHPs)

Relapse: 22% had one relapse over ve years Of those, only 26% had a repeat positive test At the end of ve years: 71% were working and licensed
18% were retired, died or licenses revoked
(Dupont RL, McLellan AT, Skipper GE. How are physicians treated? A national survey of physician health programs. J Sub Abuse Tx (2009) 37:1-7.

Tips for the First Year of Recovery

1. Residential Treatment (Inpatient or Residential Day) 2. Immediate Aftercare following Residential Treatment 3. Sober Living Environment 4. Ninety A.A. meetings in ninety days (90x90) 5. Automatic Relapse Plan 6. Testing 7. Rapid but Gradual Return to Duty 8. Addictionologist 9. Medication 10. Fun! (Hedonic Rehabilitation/Pleasure Therapy)

Relapse Plan
DO NOT PANIC! Have an Automatic Relapse Plan (previously agreed upon/no discussion) Detox (incapacitation) Return to Treatment (residential vs. outpatient) Review Testing Protocol Validate success

Daily Testing Regimen

Cocaine Amphetamine Methamphetamine THC Methadone Buprenorphine Opiates Oxycodone Propoxyphene PCP Barbiturates Benzodiazepines Alcohol (breathanalysis)

Two Kinds of Tests in Addiction Medicine

SCREENING Tests Immunoassay Very sensitive Not very specic Not an insignicant false positive rate CONFIRMATION Tests GC/MS Very, very specic Not very sensitive Forensic standard

Addictionologists
Certied by the American Society of Addiction Medicine Understand the special needs of recovering patients Not likely to make stupid mistakes Doctors who LIKE addicts, Ofces that are safe places www.asam.org www.csam-asam.org

Controlled Substances Protocol

All meds in safe ( no loose pills ) Safe behind locked door, combination changed monthly Med recording sheets/Pill Count sheets Staff tested weekly Communication with prescribing physician (rationale for Rx known)

Cost per month (Orange County numbers)

1. Therapist $150/session x 4 = 2. Addictionologist/Psychiatrist $200/visit x 2 = 3. Men s/Women s Therapy Group $60/group x 4 = $240 4. Testing $40/test x 10 = 5. Medications (prn) varies 6. Aftercare/Outpatient Program varies (may be free) 7. Sober Living Environment $500 - $1500 (& up) 8. Twelve-step meetings free $3,000 - $4,000 $600 $400 $400 - $500

$1500

National Outcome Measures (NOMs)

Abstinence Employment/Education Crime & Criminal Justice Stability in Housing Access/Capability Retention Social Connectedness Perception of Care Cost Effectiveness Use of Evidence-based Practices

Population served
Time Period: 2 years Number of Residents: 39 men Range of Duration of Stay:14 to 267 days Average Length of Stay: 98.0 days Age distribution: x = 28.9, bimodal

Performance data:
Total Delivery: 3619 resident-days Days Positive Test: 81 days (2.3%) Days Intoxicated: 83 (2.3%) Relapsed post-Tx: 48.7% Readmit Rate: 20.5% In contact/Doing well: 46.9%

LMM Outcomes
39 residents over two-year period 3615 resident-days of service delivered average length of stay was 96.9 days (range: 14 to 287) 34.4% stayed longer than originally intended 40.6% stayed shorter than originally intended 98% of resident-days were abstinent by drug and alcohol screen 23% re-admission rate (half for relapse, half for relapse prevention) 23% employed on admission 61% employed or in school at time of discharge 48 ROSC linkages created and utilized 2 DUI arrests, no probation violations 90.6% of discharged residents transitioned to stable living situations