the medical model

7/25/2019 The Medical Model

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THE MEDICAL MODEL:ADDICTION IS A BRAIN

DISEASEJudith Martin, MD

Medical Director of Su!tance "!e Ser#ice!

San $ranci!co De%t& 'ulic Health


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di!clo!ure!

( Dr& Martin ha! no conflict of intere!t to di!clo!e&

( Dr& Martin)! ia! i! that e#idence*!u%%orted, !afe

treat+ent for S"D! !hould e euital- a#ailale

throu.hout our !-!te+ of care, includin. +edication

treat+ent&

( Dr& Martin)! ia! i! that continuin. education i+%ro#e!

%atient care&

( Dr& Martin /ill indicate if !he i! di!cu!!in. off*lael u!e of

+edication!&


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Educational O0ecti#e! for thi! tal1:

( 2 learnin. o0ecti#e!

( * co+%are addiction to other chronic di!ea!e!

( * hear aout rain ada%tation! in addiction

( * li!t three +edication! that +i.ht hel% a %atient /ith S"D


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ADDICTION AS A CHRONIC ILLNESS

Chronic relapsing condition

which untreatedmay lead to severe complications

and death.


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ADDICTION AS CHRONIC

DISEASE: IM'LICATIONS

( It i! treatale ut not curale&

(Ad0u!t+ent to dia.no!i! i! %art of %atient)! ta!1&

( There i! a /ide !%ectru+ of !e#erit-&

( Retention in treat+ent i! 1e-&

( Be!t treat+ent i! inte.rated: referral! to !%eciali!t!,

eha#ior and hait! +u!t chan.e, +edication! +a-

e needed&


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Addiction i! !i+ilar to other chronic illne!!&

(Review of adherence to treatment and relapse rates in

asthma, hypertension and diabetes:( There are high relapse rates in diabetes (30 to 50%), hypertension (50!0%)

and asthma (50 to !0%) with rec"rrence of symptoms that re#"ire additional

medical care$

(omparison to addiction:( &0 to '0% ret"rn to active "se after treatment discontin"ation of treatment$

(rg"ment by analogy: addiction is a chronic disease, we

sho"ld not epect good o"tcomes from simple deto, or

for treatment that ends after 30 days$

( *c+ellan etal: -r"g -ependence, a hronic *edical .llness: I+%lication! for Treat+ent, In!urance,and Outco+e! E#aluation&

3JAMA, 4555647892;:


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T-%e! of !cience /e u!e:

( Science of eha#ior chan.e:( Sta.e! of chan.e

( Co.niti#e eha#ior thera%-

( Moti#ational incenti#e!

( Li!tenin. for lan.ua.e of chan.e: can do, !hould do, /i!h I coulddo, /ill do and reflectin. 9+oti#ational inter#ie/;

( Medical Science:

( Brain che+i!tr-, rece%tor!, tran!+itter!, tran!%orter!, inhiitor!,a.oni!t!

( Co*occurrin. condition!: needle related infection!, %!-chiatric

co+%lication!, o#erdo!e re!cue, li#er da+a.e, etc&


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ASAM definition

9A+erican Societ- of Addiction Medicine;

(Addiction i! a %ri+ar-, chronic di!ea!e of rain re/ard,

+oti#ation, +e+or- and related circuitr-& D-!function in

the!e circuit! lead! to characteri!tic iolo.ical,

%!-cholo.ical, !ocial and !%iritual +anife!tation!& Thi! i!

reflected in an indi#idual %atholo.icall- %ur!uin. re/ardand?or relief - !u!tance u!e and other eha#ior!&

( htt%:??

///&a!a+&or.?doc!?%ulic-*%olic-*!tate+ent!?definition

@of@addiction@!hort@8*&%df!f#r!n5
http://www.asam.org/docs/publicy-policy-statements/1definition_of_addiction_short_4-11.pdf?sfvrsn=0http://www.asam.org/docs/publicy-policy-statements/1definition_of_addiction_short_4-11.pdf?sfvrsn=0http://www.asam.org/docs/publicy-policy-statements/1definition_of_addiction_short_4-11.pdf?sfvrsn=0http://www.asam.org/docs/publicy-policy-statements/1definition_of_addiction_short_4-11.pdf?sfvrsn=0http://www.asam.org/docs/publicy-policy-statements/1definition_of_addiction_short_4-11.pdf?sfvrsn=0http://www.asam.org/docs/publicy-policy-statements/1definition_of_addiction_short_4-11.pdf?sfvrsn=0


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Effect! on the rain:

(Addicti#e !u!tance! are initiall-

%lea!urale&

( The re/ard center!) of the rain are !ti+ulated&9li+ic !-!te+;

( $loodin. of the rain /ith do%a+ine i! a +a0or

effect&( The re/ard center! of the rain are nor+al %art!

of u! that +a1e u! .lad, hel% u! en0o- life and

re!%ond nor+all- to other %eo%le clo!e to u!&


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Chan.e! /ith continual u!e:

( Re.ular, haitual u!e of addicti#e

!u!tance! lead to !alience) of the dru.,

and rain chan.e! called neuroada%tation)( Re/ard center i! hi0ac1ed), can no lon.er

re!%ond to nor+al !ti+uli in the !a+e /a-& 9 the

out!ide) !ti+ulu! /or1! etter no/ than the

%er!on)! o/n rain che+ical!;( 'h-!ical de%endence %roduce! tolerance ,

/ithdra/al and cra#in.


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Neuroada%tation of re/ard center!:

( De!cri%tion in NIDA)! 3Science of Addiction:

( 39the dru. u!er;e#entuall- feel! flat,

lifele!!, and de%re!!ed, and i! unale

to en0o- thin.! that %re#iou!l- rou.ht

the+ %lea!ure&

( htt%:??///&dru.au!e&.o#?%ulication!?!cience*addiction
http://www.drugabuse.gov/publications/science-addictionhttp://www.drugabuse.gov/publications/science-addiction


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Fhat 1ee%! %eo%le u!in. dru.!

( I! it ecau!e there+e+er the eu%horia and endle!!l-

!ee1 it 9%o!iti#e reinforce+ent;

( It i! ecau!e the- ha#e felt the %ain of the lac1 of dru. !o

+uch the- fear it 9ne.ati#e reinforce+ent;

( Fhich eco+e! +ore !alient)

( $or a recent deate in %rint aout thi! !ee:

( Fi!e and Goo6 3The De#elo%+ent and Maintenance of

Dru. Addiction Neuro%!-cho%har+acolo.- 9458; 2=,

4>84


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Reco#er- include! rain reco#er-:

( Durin. and after addiction treat+ent there

i! rain healin.

( So+e chan.e! +a- e %er+anent, or ta1e

a lon. ti+e to heal

( The!e chan.e! ha#e een !tudied /ith

%!-cholo.ical te!t! and al!o /ith rain

i+a.in. 9!can!;


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uote! fro+ article! aout rain reco#er-:

( co.niti#e d-!function +a- lin.er for u% to an a#era.e of

-ear %o!t*detoification fro+ alcohol&Addict Biol&452

Mar6794;:452*2

( Co.niti#e i+%air+ent reflectin. CNS di!ru%tion in chronic

!ol#ent au!er! can re!ol#e /ithin t/o -ear!

of a!tinence& Dru. Alcohol De%end&45 No# 6794*

2;:75*>&

( One +onth of a!tinence /a! !ufficient to i+%ro#e

#ariou! attentional and eecuti#e do+ain! in cocaine*de%endent !u0ect!& Dru. Alcohol De%end&458 Ma- 48&

%ii: S52K


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Dopamine transporters recover with abstinence

Volkow et al., 2001


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'h-!ical de%endence and Fithdra/al

( Fhat ha%%en! /hen -ou ha#e !to%%ed u!in. o%iate! or

drin1in. alcohol

( O%iate!: Sic1 or 1ic1in.),

( %u%il! i., !/eatin., !ha1in., lood %re!!ure ri!e!,

#o+itin., diarrhea, !nifflin. and tear!&

(Alcohol: Aniet-, tre+or!, 9DT!, !eiure! can occur;&Medication to cal+ the rain ha! eco+e !tandard for

!to%%in. alcohol in de%endent drin1er!&


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Intoication

( 9 3Hi.h or 3loaded or 3drun1;

( O%iate!: !edated, head dro%! 93Noddin.;, e-e! clo!e,

!lee%, reathin. !lo/! 9can !to% in o#erdo!e!;&

(Alcohol: lo!! of inhiition!, +i.ht do thin.! that other/i!e

/ould not, lo!! of coordination, #o+itin., lac1out!,

faintin. 9%a!!in. out;& S+ell of alcohol i! t-%ical&

( Sti+ulant!: a+%ed), tal1in. fa!t, od- +o#in., unale to

!it or !lee% or focu! 9o#erdo!e: heart attac1 or !tro1e;,

!o+eti+e! !ti+ulant %!-cho!i!&


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CRAIN

( 'reoccu%ation /ith the !u!tance

( i#id drea+! and ni.ht+are! aout u!in. !u!tance

(Auto+atic eha#ior! to .et !u!tance


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3Au!ale !u!tance!: %artial li!t

(Alcohol

( Cocaine

( Metha+%heta+ine

( Heroin( 'ain relie#er!

( Sedati#e! !uch a! enodiae%ine!

( Mari0uana

( Toacco( Su.ar 9food;

( Other:

( one a!teri!1 %er a#ailale +edication treat+ent&


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Ea+%le! of addiction treat+ent +edication!:

(Alcohol /ithdra/al treat+ent: enodiae%ine! 9u!uall- for fi#e da-!;

9!o+e !tudie! /ith anticon#ul!ant! off lael;

(Alcohol cra#in.: naltreone, to%ira+ate 9off lael;, aca+%ro!ate

(Alcohol deterrent: di!ulfira+

( O%ioid /ithdra/al !-+%to+!: +ethadone, clonidine 9off lael;,u%renor%hine 9u%renor%hine !tudied in teen!, a%%ro#ed for o#er


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Ea+%le! of #er- effecti#e +edication!: o%ioid

+aintenance +edication!

( Ma- %ro#ide u% to 75 P of effect of treat+ent in

+edication*a!!i!ted treat+ent&

( Di!continuation lead! to hi.h rela%!e rate!

( There i! a do!e*re!%on!e relation!hi%

( Outco+e on +an- front!: needle u!e, cri+inal acti#it-,

illicit o%ioid u!e, cra#in., adherence to treat+ent&


22/30

Treat+ent Outco+e Data,

Methadone +aintenance&

Treat+ent Outco+e Data,

Methadone +aintenance&( 8*> fold reduction in death rate 9ece%t fir!t /ee1;( reduction of dru. u!e

( reduction of cri+inal acti#it-

( en.a.e+ent in !ociall- %roducti#e role!

( reduced !%read of HI

( ecellent retention

9!ee: Jo!e%h et al, 4555, Mt& Sinai J&Med;


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-oseRes

ponse

Time

3+oaded/

igh/

1ormal Range

omfort 2one/

ic4/

*ethadone im"lated & r$ -ose6Response

t steadystate in tolerant patient

5

hr!&

48

hr!&

"b7ective

w6d

8b7ective w6d

O%ioid A.oni!t Treat+ent of Addiction * 'a-te * ==7


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Rela%!e to I dru. u!e after MMT5> +ale %atient! /ho left treat+ent

9ercent.:

;sers

Treatment *onths ince topping

Treatment

O%ioid A.oni!t Treat+ent of Addiction * 'a-te * ==7Ada%ted fro+ Ball Q Ro!! * The Effectiveness of Methadone MaintenanceTreatment, ==


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Re! ". C. #all, $ovember 1%, 1&%%

'lide adapted rom (om )ayte


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HI CONERSION IN TREATMENT

. infection rates by baseline treatment stat"s$ .n treatment (.T) n,

not in treatment (8T) n>

o"rce: *et?ger, -$ et$ al$ @ of .- ':=AA3$ p$=05O%ioid Maintenance 'har+acothera%- * A Cour!e for Clinician! * ==K


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Cri+e a+on. 8= %atient! efore and durin.

MMT at < %ro.ra+!

Ada%ted fro+ Ball Q Ro!! * The Effecti#ene!! of Methadone MaintenanceTreat+ent, ==

%rime-ays9erBear

O%ioid A.oni!t Treat+ent of Addiction * 'a-te * ==7


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Mean Heroin Cra#in.: < Fee1Co+%leter! of u%renor%hine trial&

=5

0

5

30

35

&0

&5

50

= 3 & 5 ' ! > A =0 == = =3 =& =5 ='

Cee4 of t"dy

= mg

& mg> mg

=' mg


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Treat+ent duration 9da-!;

Re+

ainin.intreat+

ent9nr;

5

>

5

>

45

5 >5 55 >5 455 4>5 255 2>5

Control

Bu%renor%hine

D"prenorphine *aintenance6Cithdrawal: Retention

9Ga11o et al&, 4552;


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Su++ar-:

(Addiction i! !i+ilar to +edical chronic di!ea!e in need for

lon.*ter+ treat+ent and rela%!e rate!&

(Addiction i! a!!ociated /ith rain chan.e! in the re/ard

%ath/a-!& Reco#er- i+%ro#e! rain function&

(Addiction treat+ent +edication! are u!ed alon. /ith

eha#ior !cience in treat+ent of addiction

(Addiction treat+ent +edication! are u!ed to ea!e

di!continuation of dru. u!e, and to !u%%ort lon.*ter+

reco#er- acti#itie!& Mo!t of the+ relie#e /ithdra/al andcra#in.&

the medical model

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