S' Alex Stalcup, M'D'

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S. Alex Stalcup, M.D.

• New Leaf Treatment Center
• 251 Lafayette Circle, Suite 150
• Lafayette, CA 94549
• Tel [phone]
• Fax [phone]
• alex_at_nltc.com www.nltc.com

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Definition of Addiction

• Compulsion loss of control
• The user cant not do it s/he is compelled to
  use.
• Compulsion is not rational and is not planned.
• Continued use despite adverse consequences
• An addict is a person who uses even though s/he
  knows it is causing problems.
• Addiction is staged based on adverse
  consequences.
• Craving daily symptom of the disease
• The user experiences intense psychological
  preoccupation with getting and using the drug.
• Craving is dysphoric, agitating and it feels
  very bad.
• Denial/hypofrontality distortion of cognition
  caused by craving
• Under the pressure of intense craving, the user
  is temporarily blinded to the risks and
  consequences of using.

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2000 Smoking Prevalence

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

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Dual Diagnosis

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

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Prevalence of smoking in individuals with PD and
SUD
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Nicotine and Alcohol

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

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Smoking Prevalence

• 75.5 ever smoked
• 63.3 smoked whole cigarette
• 42.8 ever smoked daily
• 21.7 ever nicotine dependent
• 14.1 current nicotine dependence

• 42.8 ever smoked daily
• ?
• 53.1 ever nicotine dependent
• ?
• 66.2 current dependence

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Tobacco Dependence is a Pediatric Disease

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

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Prenatal Nicotine Exposure in Rat Pups

• Fig. 1 ADHD
• Increased locomotion
• Fig. 2 ADDICTION
• Increased preference for cocaine
• Fig. 3 DEPRESSION
• Increased learned helplessness

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Adjusted Odds Ratio for ADHD among US Children by
Prenatal Tobacco Exposure and Sex
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What is a Drug?

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

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Neuroadaptation

• In direct response to overstimulation, brain
  regions decrease in sensitivity and
  responsiveness. Brain regions become
  unresponsive (deaf) to usual levels of
  stimulation, a process by which the reward and
  pleasure centers of the brain adapt to high
  concentrations of pleasure neurotransmitters
  (tolerance).
• Under unstimulated conditions (without drugs)
  there is profound interference with the ability
  to experience normal pleasure. When sober, the
  user feels anhedonia, anxiety, anger, frustration
  and craving.
• In addition to pleasure neuroadaptation, other
  brain pathways stimulated by drugs also become
  under active, directly leading to anxiety,
  depression, and loss of energy.
• Once neuroadapted, the pleasure system remains
  impaired for months to years, interfering with
  sobriety, learning, and impulse inhibition.

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Principles of Addiction Biology

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

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Environmental Cueing Conditioned Craving

• Drug pleasure becomes associated with specific
  people, places, and things to encounter any of
  those things in the environment is to trigger
  craving for the drug. Such triggers persist for
  decades after use.

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Behavior Control The Balance Concept
Forebrain
Decision Making
Logic
Drug Craving
Judgment
Cueing
Ethics
Hunger
Salience (weighing value)
Greed
Lust
Weighing consequences
Fear
Rage
Jealousy
Midbrain
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?D2 Hypofrontality

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

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Addiction Pathophysiology

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

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Nicotine EffectsReceptor Activation

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

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Nicotine Receptor Activation
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Brain Circuit Neuroadaptation

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

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Nicotine EffectsWithdrawal Symptoms

• Mentally sluggish
• Inattentive
• Insomnia
• Boredom and dysphoria
• Fatigue
• Anxiety
• Increase pain sensitivity
• Worsen cognitive function

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Differences in Neuroadaptation between Nicotine
and other Addicting Drugs

• Tolerance to most drugs develops over weeks to
  months and resolves in months to years.
• Tolerance to nicotine develops over a single day
  and resolves over night.

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Model for nicotine addiction cycle during daily
cigarette smoking.
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RISK OF ADDICTION

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

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Bio-Psycho-Social Model

• Predisposition
• Genetics
• Childhood Sexual Abuse
• Mental Illness
• Acquired Hypofrontality
• in utero alcohol/drug exposure low birth
  weight
• perinatal asphyxia head injury
• The Drug / Circumstances of First Use
• Enabling System

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Addiction Risk Resilience

• Inherited predisposition (genetics)
• Childhood trauma or abuse
• Unwanted sexual involvement before age 13
• Mental Illness depression, anxiety, personality
  disorder
• Attention Deficit Disorder (ADD)
• Learning disabilities/school failure
• Subjected to teasing, bullying
• Acne and/or obesity
• Other than heterosexual orientation
• Social rejection
• Early sexual involvement
• Onset of drug use before age 16
• Enabling environment
• Ignorance

• No family history of addiction
• Good mental health
• Academic competence
• Positive relationship with an adult
• Family eats dinner together 5 days/wk
• Peer group participation (clubs)
• Participation in sports
• Participation in music, drama or dance
• Involvement in faith-based activities
• Taking care of pets
• Volunteer activities
• Social acceptance
• Environment disapproves of drug use
• Immediate, appropriate scaled consequences for
  alcohol/drug use.
• Early intervention for alcohol/drug use

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Smoking Trajectories of Adolescent Novice Smokers

• 72.4
• Did not progress to addiction
• School has clear rules on smoking
• 27.6 Did progress to addiction
• Development of nicotine dependence
• Poor academic performance
• More than half of friends smoke
• Students smoke despite school rules
• Parents smoke nicotine
• Teachers/staff smoke near school
• Co-morbidity highly prevalent

• 11.1
• Slow Use Escalation
• Female gender
• 10.8
• Moderate Use Escalation
• Female gender
• 5.7
• Rapid Use Escalation
• Male gender
• High co-morbidity
• Strong family history for addiction

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Goals of Assessment
Generation of a Treatment Plan

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

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Are you at Risk?

• Apply the bio-psycho-social model to yourself
• Do you have a family history of addiction?
• Do you have a tendency to boredom or ADHD?
• Are you anxious or depressed?
• Have you suffered sexual trauma?
• Do you have an effective way to manage stress?

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Are you in trouble?

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

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Are You an Addict?

• TRY THE EXPERIMENT
• Resolve not to use for 5 weeks.
• Go about your usual daily activities.
• Put yourself around the drug and people using it.

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Are You an Addict?

• AFTER 5 WEEKS
• Were you able to not use?
• Did you find your mind talking you into using?
  Did you struggle not to use?
• Were you able to have pleasure without using?
• Did you have problems with boredom, depression or
  anxiety?

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What to do

• Get out of the using environment.
• Find alternative sources of pleasure.
• Work on balancing stress.
• Seek help for mental health issues and other
  personal stresses.

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Definition of Addiction

• Compulsion loss of control
• The user cant not do it s/he is compelled to
  use.
• Compulsion is not rational and is not planned.
• Continued use despite adverse consequences
• An addict is a person who uses even though s/he
  knows it is causing problems.
• Addiction is staged based on adverse
  consequences.
• Craving daily symptom of the disease
• The user experiences intense psychological
  preoccupation with getting and using the drug.
• Craving is dysphoric, agitating and it feels
  very bad.
• Denial/hypofrontality distortion of cognition
  caused by craving
• Under the pressure of intense craving, the user
  is temporarily blinded to the risks and
  consequences of using.

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C I M Model TreatmentCraving Identification
and Management
Stalcup SA, Christian D, Stalcup JA, Brown M,
Galloway GP. A treatment model for craving
identification and management. Journal of
Psychoactive Drugs. 38235-44, 2006
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C I M Model Treatment Causes of Craving

• Environmental cues (Triggers)
• immediate, catastrophic, overwhelming craving
  stimulated by people, places, things associated
  with prior drug-use experiences
• Drug withdrawal
• inadequately treated or untreated
• Mental illness symptoms
• inadequately treated or untreated
• Stress equals craving

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C I M Model TreatmentComponents of Treatment

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

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TOBACCO CESSATION Initiating Abstinence

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

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TOBACCO CESSATION Relapse Prevention

• Monitor use, craving scores, adherence to plan
• Modify plan to address weaknesses
• Continue modified plan, assess craving scores and
  craving causes
• Monthly telephone follow up calls

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C I M Model TreatmentDetoxification

• Use of medications to treat
• withdrawal symptoms.

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Continuous abstinence with varenicline,
bupropion, placebo
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C I M Model TreatmentAvoidance Strategies

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

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C I M Model TreatmentRecovery Tools

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

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C I M Model TreatmentRelapse Prevention

• Questions about Craving
• What is your craving score?
• What is the cause of your craving?
• Environmental cue
• Stress
• Drug withdrawal
• Mental health problems
• What will you do to take care of yourself?
• Avoidance strategies
• Stress Management
• Tools
• Program activities

• Principles
• Addicted persons relapse because of craving.
• Craving has causes that can be predicted,
  recognized and analyzed.
• Craving can be managed with the use of program
  activities.

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RECOVERY COACHING

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

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Treatment works!

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

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Prevention

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

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REFERENCES

• Benowitz N. Neurobiology of nicotine addiction
  implications for smoking cessation treatment.
  American Journal of Medicine. 121(4A) S3-S10
  (2008).
• Bechara A. Decision making, impulse control and
  loss of willpower to resit drugs a
  neurocognitive perspective. Nature Neuroscience.
  81458-63 (2005)
• Dackis C, OBrien C. Neurobiology of addiction
  treatment and public policy ramifications. Nature
  Neuroscience. 8(11)1431-6 (2005).
• Nestler EJ, Malenka RC. The addicted brain.
  Scientific American.com February 9, 2004.
• Stalcup SA, Christian D, Stalcup JA, Brown M
  Galloway GP. A treatment model for craving
  identification and management. Journal of
  Psychoactive Drugs. 38235-44, 2006
• Volkow ND, Fowler JS, Wang GJ. The addicted human
  brain insights from imaging studies. Journal of
  Clinical Investigation. 111(101444-51 (2003).
• Weinberger DR, Elvevag B, Giedd JN. The
  adolescent brain a work in progress. National
  Campaign to Prevent Teen Pregnancy. June 2005.