Disease concept 041313 farley

ARE ALCOHOLISM & DRUG ARE ALCOHOLISM & DRUG ADDICTION REALLY ADDICTION REALLY

DISEASES, AND IF SO, DISEASES, AND IF SO, SO WHAT ?SO WHAT ?

THE FARLEY CENTERTHE FARLEY CENTER04/13/1304/13/13

WILLIAMSBURG, VAWILLIAMSBURG, VA

LYNN LYNN HANKESHANKES, MD, FASAM, MD, FASAM

Clinical Professor EmeritusClinical Professor EmeritusClinical Professor EmeritusClinical Professor Emeritus

Department of PsychiatryDepartment of Psychiatry

and Behavioral Scienceand Behavioral Science

University of Washington University of Washington

School of MedicineSchool of Medicine

SeattleSeattle

ADDICTIONADDICTION

ALCOHOLISMALCOHOLISM

& ANY & ANY OTHEROTHER

DRUG DEPENDENCY DRUG DEPENDENCY ==

CHEMICAL DEPENDENCYCHEMICAL DEPENDENCY

CHEMICAL IS ADDICTIVE IFCHEMICAL IS ADDICTIVE IF

1. MIND ALTERING1. MIND ALTERING--MOOD CHANGINGMOOD CHANGING1. MIND ALTERING1. MIND ALTERING--MOOD CHANGINGMOOD CHANGING

2. REINFORCING2. REINFORCING

3. EUPHORIGENIC3. EUPHORIGENIC

NOT ADDICTIVENOT ADDICTIVE

�� ANTIDEPRESANTSANTIDEPRESANTS

�� LITHIUMLITHIUM

�� ANTIANTI--PSYCHOTICSPSYCHOTICS

CHEMICAL CLASSESCHEMICAL CLASSES

��OPIOIDSOPIOIDS

��SEDATIVESEDATIVE--HYPNOTICSHYPNOTICS

��STIMULANTSSTIMULANTS

��PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS

��CANNABINOIDSCANNABINOIDS

�� INHALANTSINHALANTS

ADDICTIVE POTENTIALADDICTIVE POTENTIAL

�� COCAINE/METHAMPHETAMINECOCAINE/METHAMPHETAMINE

�� SYNTHETIC OPIOIDS (FENTANYL)SYNTHETIC OPIOIDS (FENTANYL)

�� HEROINHEROIN�� HEROINHEROIN

�� MINOR OPIOIDSMINOR OPIOIDS

�� NICOTINENICOTINE

�� ALCOHOLALCOHOL

ADDICTIVE POTENTIALADDICTIVE POTENTIAL

�� OTHER SEDATIVESOTHER SEDATIVES

�� OTHER STIMULANTSOTHER STIMULANTS

�� PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS�� PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS

�� CANNABINOIDSCANNABINOIDS

�� CAFFEINECAFFEINE

U.S. MORTALITYU.S. MORTALITY

�� ILLEGAL DRUGSILLEGAL DRUGS

�� ALCOHOLALCOHOL

�� 10 PER DAY10 PER DAY

�� 400 PER DAY400 PER DAY�� ALCOHOLALCOHOL

�� ??

�� NICOTINENICOTINE

�� 400 PER DAY400 PER DAY

�� 1000 PER DAY1000 PER DAY

DEPENDENCYDEPENDENCY

�� Loss Of Loss Of CControlontrol

�� CCompulsive Useompulsive Use�� CCompulsive Useompulsive Use

�� Continued Use Despite Continued Use Despite Adverse Adverse CConsequencesonsequences

ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS

�� IGNORANTIGNORANT

��STUPIDSTUPID

��CRAZYCRAZY

�� IMMORALIMMORAL

��WEAKWEAK

��SICKSICK

ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS

IGNORANTIGNORANTIGNORANTIGNORANT

STUPIDSTUPIDEDUCATIONEDUCATION

ACTIVITYACTIVITY------PROBLEMSPROBLEMS

��CRAZYCRAZY ��PSYCHOPSYCHO--TXTX

ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS

IMMORALIMMORAL CHURCH/JAILCHURCH/JAIL

ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS

WEAKWEAK

WILLEDWILLED“JUST SAY NO“JUST SAY NO””

ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS

SICKSICK TREATMENTTREATMENT

DISEASEDISEASE

A DYSFUNCTIONAL A DYSFUNCTIONAL A DYSFUNCTIONAL A DYSFUNCTIONAL STATE WITH STATE WITH CHARACTERISTIC CHARACTERISTIC FORMFORM

CHARACTERISTIC FORMCHARACTERISTIC FORM

��CAUSECAUSE

��SPECIFIC DEFECTSPECIFIC DEFECT

��SXSX--SIGNSSIGNS--LAB TESTSLAB TESTS��SXSX--SIGNSSIGNS--LAB TESTSLAB TESTS

��PREDICTABLE COURSEPREDICTABLE COURSE

��UNIFORM TREATMENTUNIFORM TREATMENT

��SIMILAR RESPONSESIMILAR RESPONSE

COMPARE DISEASESCOMPARE DISEASES

��DIABETESDIABETES

��AIDSAIDS��AIDSAIDS

��CHEMICAL CHEMICAL DEPENDENCYDEPENDENCY

DIABETESDIABETES

��CAUSECAUSE

��DEFECTDEFECT

��UNKNOWNUNKNOWN�� Insulin ImbalanceInsulin Imbalance

YESYES��SXSX--SIGNSSIGNS--LABLAB

��COURSECOURSE

��SAME TXSAME TX

��RESPONSERESPONSE

��YESYES

��YESYES

�� DietDiet--PillsPills--InsulinInsulin

��YESYES

AIDSAIDS

��CAUSECAUSE

��DEFECTDEFECT

��HIV +/HIV +/-- CoCo--FF

��T 4 CELLT 4 CELL

��SXSX--SIGNSSIGNS--LABLAB

��COURSECOURSE

��SAME TXSAME TX

��RESPONSERESPONSE

��YESYES

��YESYES

��UNKNOWNUNKNOWN

��N/AN/A

CHEMICAL DEPENDENCYCHEMICAL DEPENDENCY

��CAUSECAUSE

��DEFECTDEFECT

��UNKNOWNUNKNOWN�� CHEM/PSY IMBLNCECHEM/PSY IMBLNCE

YESYES��SXSX--SIGNSSIGNS--LABLAB

��COURSECOURSE

��SAME TXSAME TX

��RESPONSERESPONSE

��YESYES

��YESYES�� AAAA--OUT PTOUT PT--IN PTIN PT

��YESYES

“MEDICALIZE”“MEDICALIZE”-- IT’S A IT’S A DISEASE BECAUSE:DISEASE BECAUSE:

�� BEING SICK IS LESS SHAMEFUL THANBEING SICK IS LESS SHAMEFUL THAN

WILLFUL MISCONDUCTWILLFUL MISCONDUCTWILLFUL MISCONDUCTWILLFUL MISCONDUCT

�� THEN INSURANCE WILL PAY FOR TXTHEN INSURANCE WILL PAY FOR TX

�� HAVING AN ILLNESS ABSOLVES ONE HAVING AN ILLNESS ABSOLVES ONE

FROM SOCIAL RESPONSIBILITYFROM SOCIAL RESPONSIBILITY

DISEASE CHARACTERISTICSDISEASE CHARACTERISTICS

��CHRONICCHRONIC

��PRIMARYPRIMARY��PRIMARYPRIMARY

��PREDICTABLEPREDICTABLE

��“CATCHING”“CATCHING”

CHRONICITYCHRONICITYPERMANENTPERMANENT

NOT ALCOHOLNOT ALCOHOL--WASWAS--MM

BUT ALCOHOLBUT ALCOHOL--------ISIS--MM

PRONE TO RELAPSEPRONE TO RELAPSE

DIABETESDIABETES

CORONARY INSUFFICIENCYCORONARY INSUFFICIENCY

ALCOHOLISMALCOHOLISM

PRIMARYPRIMARY

�� PRIMARY: Stands alone independentlyPRIMARY: Stands alone independently

�� SECONDARY: To underlying primary ds.SECONDARY: To underlying primary ds.

NEUROSISNEUROSISNEUROSISNEUROSIS

PSYCHOSISPSYCHOSIS

PREDICTABLEPREDICTABLE

Often progressive in 4 Stages:Often progressive in 4 Stages:

EARLYEARLY---->>EARLYEARLY---->>

MIDDLEMIDDLE---->>

LATELATE---->>

TOO LATE +TOO LATE +

“CATCHING”“CATCHING”

THE ________ IS “CATCHING”THE ________ IS “CATCHING”

THE THE INSANITYINSANITY IS “CATCHING!”IS “CATCHING!”THE THE INSANITYINSANITY IS “CATCHING!”IS “CATCHING!”

The stress of living with an alcoholic The stress of living with an alcoholic produces dysfunctional coping behavior produces dysfunctional coping behavior similar to that in post traumatic stress similar to that in post traumatic stress syndrome !!syndrome !!

WHO ?WHO ?

EVERYONEEVERYONEEVERYONEEVERYONE

FROM “YALE TO JAIL”FROM “YALE TO JAIL”

QUESTION ?QUESTION ?

A. A. YOU’RE ALCOHOLICYOU’RE ALCOHOLIC

BECAUSE YOU DRINK TOO BECAUSE YOU DRINK TOO MUCHMUCHMUCHMUCH

B. B. YOU DRINK TOO MUCH YOU DRINK TOO MUCH BECAUSE YOU’RE BECAUSE YOU’RE ALCOHOLICALCOHOLIC

ANSWER !ANSWER !

B. YOU DRINK TOO B. YOU DRINK TOO B. YOU DRINK TOO B. YOU DRINK TOO MUCH BECAUSE MUCH BECAUSE YOU’RE ALCOHOLICYOU’RE ALCOHOLIC

OLD THEORYOLD THEORY

HEAVY DRINKINGHEAVY DRINKING------>>

ABUSEABUSE------>>

ALCOHOLISMALCOHOLISM

ALCOHOL ABUSEALCOHOL ABUSE

�� MEDICATE STRESSMEDICATE STRESS

�� MEDICATE MENTAL ILLNESSMEDICATE MENTAL ILLNESS

�� MOST TEENAGERSMOST TEENAGERS�� MOST TEENAGERSMOST TEENAGERS

�� MOST COLLEGE STUDENTSMOST COLLEGE STUDENTS

�� SOCIOPATHSSOCIOPATHS

NEW THEORYNEW THEORY

SOCIAL DRINKINGSOCIAL DRINKING

(NORMAL)(NORMAL)

ABUSEABUSE

(DISORDER)(DISORDER)

ALCOHOLISMALCOHOLISM

(DISEASE)(DISEASE)

NEW THEORYNEW THEORY

SOCIAL DRINKINGSOCIAL DRINKING

(CAN STOP)(CAN STOP)

ABUSEABUSE

(MIGHT STOP)(MIGHT STOP)

ALCOHOLISMALCOHOLISM

(CAN’T STOP)(CAN’T STOP)

DOUBLE MARTINI DOUBLE MARTINI TESTTEST

HEAVY DRINKERHEAVY DRINKER

ABUSERABUSER

ALCOHOLICALCOHOLIC

“…the addicted brain is, in fact, “…the addicted brain is, in fact, different in its neurobiology different in its neurobiology from the nonfrom the non--addicted brain.”addicted brain.”

Alan Leshner, Ph.D.Alan Leshner, Ph.D.

Director, NIDADirector, NIDA

DRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESS

www.drugabuse.gov

“ …a drug hijacks one’s brain, “ …a drug hijacks one’s brain, thereby hijacking one’s mind, and thereby hijacking one’s mind, and then one’s life.”then one’s life.”

Alan Leshner, Ph.D.Alan Leshner, Ph.D.

Director, NIDADirector, NIDA

BASIC BRAIN FUNCTIONBASIC BRAIN FUNCTION

�� All systems in balanceAll systems in balance

�� Chemical messengers:Chemical messengers:

––act fastact fast

––short durationshort duration

––small amountssmall amounts

ALCOHOL & DRUGSALCOHOL & DRUGS

�� Alter the balance of the systemAlter the balance of the system

�� Change the messengers:Change the messengers:

––slowed downslowed down

––prolonged actionprolonged action

––decreased responsedecreased response

www.drugabuse.gov

SPECT/PET SCANSSPECT/PET SCANS

�� ALTERS BRAIN BLOOD FLOWALTERS BRAIN BLOOD FLOW

––INCREASEDINCREASED to areas to areas ––INCREASEDINCREASED to areas to areas

required for drug userequired for drug use

–– decreaseddecreased to areas of thinking, to areas of thinking, learning, and memorylearning, and memory

controlcontrol on cocaineon cocaine

www.drugabuse.gov

SPECT / PET ScansSPECT / PET Scans

��Reduced brain glucoseReduced brain glucose

(70(70--80% of brain energy)80% of brain energy)(70(70--80% of brain energy)80% of brain energy)

��Decreased brain functionDecreased brain function

WHY LOSS OF CONTROL ?WHY LOSS OF CONTROL ?

�� ALTERED BLOOD FLOWALTERED BLOOD FLOW

�� ALTERED MESSENGERS & EFFECTSALTERED MESSENGERS & EFFECTS

�� DECREASED BRAIN GLUCOSEDECREASED BRAIN GLUCOSE�� DECREASED BRAIN GLUCOSEDECREASED BRAIN GLUCOSE

�� DECREASED BRAIN DOPAMINEDECREASED BRAIN DOPAMINE

�� CELLULAR CHANGE OR DAMAGECELLULAR CHANGE OR DAMAGE

SPECT / PET ScansSPECT / PET Scans

�� Cellular damageCellular damage

SO IT’S A DISEASE !SO IT’S A DISEASE !

SO WHAT ?SO WHAT ?SO WHAT ?SO WHAT ?

CHRONICITYCHRONICITYPERMANENTPERMANENT

NO RETURN TO SOCIAL DRINKINGNO RETURN TO SOCIAL DRINKING

NO RECREATIONAL DRUG USENO RECREATIONAL DRUG USE

PRONE TO RELAPSEPRONE TO RELAPSE

BUILD A DEFENSE VS. 1ST DRINKBUILD A DEFENSE VS. 1ST DRINK

RECOVERY REQUIRES MAINTENANCERECOVERY REQUIRES MAINTENANCE

“There exists, therefore, outside of “There exists, therefore, outside of alkaloids and habit, a sense for alkaloids and habit, a sense for

opium, an intangible habit which opium, an intangible habit which lives on, despite the recasting of the lives on, despite the recasting of the

organism. The dead drug leaves a organism. The dead drug leaves a ghost behind. At certain hours it ghost behind. At certain hours it ghost behind. At certain hours it ghost behind. At certain hours it

haunts the house.”haunts the house.”

JeanJean CocteauCocteau

French AuthorFrench Author18891889--19631963

“ We are unable, at certain times, to “ We are unable, at certain times, to bring into our consciousness with bring into our consciousness with sufficient force the memory of suffering sufficient force the memory of suffering and humiliation of even a week or a and humiliation of even a week or a month ago.” month ago.”

Alcoholics AnonymousAlcoholics Anonymous

AA World Services, IncAA World Services, Inc

New York, New York, 19391939

Childress, 1999Childress, 1999

MAINTAINENCEMAINTAINENCE

ALCOHOLICS ALCOHOLICS ALCOHOLICS ALCOHOLICS ANONYMOUSANONYMOUS

MAINTENANCEMAINTENANCE

ALCOHOLICS ANONYMOUSALCOHOLICS ANONYMOUSALCOHOLICS ANONYMOUSALCOHOLICS ANONYMOUS

AA is evidenced based, empirically

validated, and scientifically established

as the best form of maintenance

treatment to date!

PRIMARYPRIMARY

NO UNDERLYING DISEASE TO TXNO UNDERLYING DISEASE TO TX

TOTAL ABSTINENCE IS NECESSARYTOTAL ABSTINENCE IS NECESSARYTOTAL ABSTINENCE IS NECESSARYTOTAL ABSTINENCE IS NECESSARY

Willam Silkworth, MD:Willam Silkworth, MD:

“…the action of alcohol on these chronic “…the action of alcohol on these chronic alcoholics is a manifestation of an alcoholics is a manifestation of an allergyallergy.” (page xxviii).” (page xxviii)

Alcoholics AnonymousAlcoholics Anonymous

AA World Services, IncAA World Services, Inc

New York, New York, 19391939

ALLERGYALLERGY

�� TO PENICILLINTO PENICILLIN

�� TO MILKTO MILK�� TO MILKTO MILK

�� TO ALCOHOLTO ALCOHOL

Therefore, Therefore,

TOTAL ABSTINENCETOTAL ABSTINENCE

PATHOLOGYPATHOLOGY

TARGET ORGAN=BRAINTARGET ORGAN=BRAIN

DEFECT=CHEMICAL IMBALANCEDEFECT=CHEMICAL IMBALANCE

THEN: THEN: AVOIDAVOID THE CHEMICALTHE CHEMICAL

AVOIDANCE=AVOIDANCE=ABSTINENCEABSTINENCE

ABSTINENCE=TOTALABSTINENCE=TOTAL

TOTAL ABSTINENCETOTAL ABSTINENCE

AVOID ALL LIKE DRUGS:AVOID ALL LIKE DRUGS:

��BARBITURATESBARBITURATES

��NONNON--BARBITURATE SEDATIVESBARBITURATE SEDATIVES

��BENZODIAZEPINESBENZODIAZEPINES

––ANXIOLYTICSANXIOLYTICS

––HYPNOTICSHYPNOTICS

TOTAL ABSTINENCETOTAL ABSTINENCE

AVOID ALL ADDICTIVE DRUGS:AVOID ALL ADDICTIVE DRUGS:

�� OPIOIDSOPIOIDS

�� STIMULANTSSTIMULANTS

�� PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS

�� CANNABINOIDSCANNABINOIDS

�� INHALANTSINHALANTS

TOTAL ABSTINENCETOTAL ABSTINENCE

CAUTION OTHER DRUGS:CAUTION OTHER DRUGS:

�� OTC DECONGESTANTSOTC DECONGESTANTS

�� OTC ANTIHISTAMINESOTC ANTIHISTAMINES�� OTC ANTIHISTAMINESOTC ANTIHISTAMINES

�� STEROIDSSTEROIDS

�� MUSCLE RELAXANTSMUSCLE RELAXANTS

��“NON“NON--ADDICTIVE” ANALGESICSADDICTIVE” ANALGESICS

��“NON“NON--ADDICTIVE” SEDATIVESADDICTIVE” SEDATIVES

PREDICTABLEPREDICTABLE

ONLY 3 OPTIONS:ONLY 3 OPTIONS:

LOCKED UPLOCKED UP

COVERED UPCOVERED UP

SOBER UPSOBER UP

“CATCHING”“CATCHING”

ADDICTION IS A FAMILY AFFLICTIONADDICTION IS A FAMILY AFFLICTION

THEREFORE: TX THE FAMILY AS WELL !THEREFORE: TX THE FAMILY AS WELL !

SPOUSE/ S OSPOUSE/ S O

�� COCO--DEPENDENCY TREATMENTDEPENDENCY TREATMENT�� COCO--DEPENDENCY TREATMENTDEPENDENCY TREATMENT

�� ALAL--ANONANON

CHILDRENCHILDREN

�� FAMILY THERAPYFAMILY THERAPY

�� ACOA (Adult Children Of Alcoholics)ACOA (Adult Children Of Alcoholics)�� ACOA (Adult Children Of Alcoholics)ACOA (Adult Children Of Alcoholics)

�� ALAALA--TEENTEEN

�� ALAALA--TOTTOT

ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS

�� IGNORANTIGNORANT

��STUPIDSTUPID

��CRAZYCRAZY

�� IMMORALIMMORAL

��WEAKWEAK

��SICKSICK

THEREFORE, ADDRESSTHEREFORE, ADDRESS

�� NOT NOT MORALLYMORALLY

�� BUT BUT MEDICALLYMEDICALLY�� BUT BUT MEDICALLYMEDICALLY

�� WITH:WITH:

––DIGNITYDIGNITY

––PRIVACYPRIVACY

––CONFIDENTIALITYCONFIDENTIALITY

REFERENCEREFERENCELewis, DC: A Disease Model of Lewis, DC: A Disease Model of

Addiction. In NS Miller & MC Addiction. In NS Miller & MC Doot (eds.) Doot (eds.) Principles of Principles of Addiction Medicine Addiction Medicine (1994). (1994). Addiction Medicine Addiction Medicine (1994). (1994). Chevy Chase, Maryland, Chevy Chase, Maryland, American Society of Addiction American Society of Addiction Medicine, section 1, Chapter 7, Medicine, section 1, Chapter 7, pages 1pages 1--8.8.

THE “MESSAGE”THE “MESSAGE”

�� C D=ALCOHOLISM & ANY C D=ALCOHOLISM & ANY OTHER OTHER DDDD

�� C D=A DISEASE STATEC D=A DISEASE STATE

�� NO ONE IS IMMUNENO ONE IS IMMUNE�� NO ONE IS IMMUNENO ONE IS IMMUNE

�� DENIAL=CHIEF SXDENIAL=CHIEF SX----MAJOR OBSTACLEMAJOR OBSTACLE

�� INTERVENTION IS NECESSARYINTERVENTION IS NECESSARY

THE “THE “MESSAGEMESSAGE””

�� TX = BIOTX = BIO--PSYCHOPSYCHO--SPIRITUALSPIRITUAL

�� AA/NA IS ESSENTIALAA/NA IS ESSENTIAL

MONITORING IS CRITICALMONITORING IS CRITICAL�� MONITORING IS CRITICALMONITORING IS CRITICAL

�� TX WORKS W/UNALTERED RXTX WORKS W/UNALTERED RX

�� REHABILITATEREHABILITATE

�� DON’T TERMINATEDON’T TERMINATE