“The role of primary care in recovery from addiction”

GP and Practice Nurse Weekend Away Conference

Beachfront HokitikaNovember 2012

Doug SellmanProfessor of Psychiatry and Addiction Medicine

Director, National Addiction CentreUniversity of Otago, Christchurch

National Addiction CentreUniversity of Otago, Christchurch

Shortcut to Sitting at desk 1.JPG.lnk

“Ten things the alcohol industry won’t tell you about alcohol”

Six medical things the alcohol industry won’t tell you about alcohol

1. Alcohol is a highly intoxicating drug with a relatively low safety index

2. Alcohol is a neurotoxin which can cause brain damage

3. Alcohol can directly cause aggression

4. Alcohol is fattening in moderate drinkers

5. Alcohol can cause cancer

6. Alcohol cardio-protection has been talked up

Three more things the alcohol industry definitely won’t tell you

about alcohol

7. The alcohol industry actively markets alcohol to young people

8. Low risk drinking means drinking low amounts of alcohol

9. A lot of the alcohol industry’s profit comes from heavy drinking

A final thing the alcohol industry will do their very best to stop you

knowing about

10. The “5+ Solution”

To the national alcohol crisis:New Zealand’s heavy drinking

culture

The 5+ Solution

• Raise alcohol prices

• Raise the purchase age

• Reduce alcohol accessibility

• Reduce advertising and sponsorship

• Increase drink-driving counter-measures

PLUS: Increase treatment opportunities for heavy drinkers

Based on Babor et al (2003, 2010) Confirmed by Anderson et al (2009)

Three questions

1. What is addiction?

2. What is recovery from addiction?

3. What is the role of primary care in recovery from addiction?

The Case of John

John is a 35 year old man who is in a five year de facto relationship with Mary and her three children.

He works as a gib stopper and they all live together in a Housing NZ house.

Addiction History

John has been smoking 20 cigarettes a day and engaging in a session of cannabis use most evenings for the past twenty years.

Since living with Mary he has begun drinking alcohol increasingly heavily, now 8-10 stubbies of beer most evenings, and has moderate-severe alcohol dependence.

He has recently started using methamphetamine with binges lasting 2-3 days occurring once or twice a month, but doesn’t yet meet criteria for dependence.

Other Relevant History

Mary, who is pregnant to John, consumes less than half of the alcohol John does and has two or three non-drinking days a week.

John has suffered periods of significant depression since his mid-teens which have become more severe in recent years exacerbated by his heavy drinking.

John has seen his GP in the past for treatment of depression, but the GP has now been alerted to his heavy drinking, due to Mary presenting for help with bruising around her neck following an altercation when she and John were both intoxicated.

What is addiction?

Addiction continuum

No Low risk Hazardous Problem Mild Moderate/severeuse use use use dependence dependence

Addiction continuum

No Low risk Hazardous Problem Mild Moderate/severeuse use use use dependence dependence

ADDICTIONADDICTION APPRENTICESHIP

Sociopathic Personality

Disturbance

Alcoholism Alcoholism

Alcohol Abuse

AlcoholDependence

Antisocial Personality Antisocial Personality

Disorder

DSM1(1952)

DSM2 / ICD 8(1968) (1969)

ICD9 / DSM3 / DSM3-R / ICD10 DSMIV(1977) (1980) (1987) (1992) (1994)

SHIFTS IN THE DIAGNOSIS OF ALCOHOLISM OVER THE PAST 50 YEARS

DSM-IV SUBSTANCE DEPENDENCE

Dyscontrol

Salience

Compulsion to use

Physiological changes

DSM-IV SUBSTANCE DEPENDENCE

Maladaptive pattern of use with at least three of the following

occurring within a 12 month period:

1. Use is often more than intended (quantity or time)

2. Unsuccessful attempts to cut down or control use

3. Much time is spent in use (time +++)

4. Important activities given up or reduced

5. Continued use despite knowledge of associated medical or psychological problems

6. Tolerance (acquired)

7. Withdrawal

A fundamental question

How much “free will” does a person with addiction have?

Addiction is fundamentally about compulsive behaviour

Behaviour associated with the addictive object

- alcohol, other drugs, electronic gambling machines, pornographic websites, hedonic food etc -

becomes increasingly driven by limbic forces

Source: MacLean, 1973

                                                                                                                                                                                                      

The major brain areas and lobes. Image from Purves

Two neural systemssignalling pain or pleasure

1. Pain or pleasure of the immediate prospects of an option

2. Pain or pleasure of the future prospects of an option

Burns & Bechara (2007)

InhibitoryDysfunction

RewardOverdrive

Drug DrugUse Craving

Neural Circuitry of Addiction(Hammer 2002)

Compulsive drug seeking is initiated outside of consciousness

• “Free won’t” (Obhi & Haggard 2004) is half a second behind the ‘decision’

• Half second delay required to ‘crank up’ consciousness in the human brain in response to an external cue (Libet et al 1983)

Two more fundamental questions

What causes addiction?

What is more important in determining whether a person becomes addicted or not – early family environment or genetics?

EVIDENCE FOR A GENETIC INFLUENCE IN CAUSING

ALCOHOLISM

Family Studies

Twin Studies

Adoption Studies

Animal Models

Molecular Genetics

TWIN STUDIES

Concordance Rate

Dizygotic (non-identical) 10-15%

Monozygotic (identical) 30-40%

ANIMAL MODELS

* A group of wild strain rats placed in an experimental area* Given a choice of water or an alcohol solution to drink* Rats observed regarding interest in drinking alcohol* Interested rats taken out and inbred* Progeny placed back into the experimental area and study repeated* Twelve generations of inbreeding will produce an “alcohol-preferring rat”

ANIMAL MODELS (CONT)

* Existing in all mammalian species is the trait of “high volume vs low volume” fluid drinking

* The traits of “alcohol preferring” and “high volume” have been combined to produce a “high volume/alcohol preferring” rat

High-volume alcohol-preferring rat

Height80-100%

WeightSchizophreniaBipolar Illness

60-80%

IQPlasma cholesterolAdult-onset diabetes

Alcohol and drug dependence

40-60%

MIBlood pressurePersonality

Anxiety disordersDepressionBulimia

20-40%

LanguageReligion

zero

Other Important Familial Traits

Psychiatric Disorders

Heritability

Heritability Of Psychiatric Disorders (Kendler 2003)

How many genes?

1982 3 – 4 genes

2012 300 – 400 genes

“Nature via Nurture:Genes, Experience & What Makes Us Human” (2003)

Matt Ridley (1958-present)

Behind every addiction is an INDUSTRY

pushing a moreish product

Behind every addiction there is an industry scheming to make you and your children one of their favourite customers

for life

Behind every thriving addictionogenic industry is a very appreciative

government

The New Zealand Way of Life NZ’s heavy drinking culture

• 25% of New Zealand drinkers are heavy drinkers, which amounts to 700,000+ people

• A third of all police apprehensions involving alcohol

• Half of serious violent crimes relating to alcohol

• Over 300 alcohol-related offences every day

• Up to 3000 children born each year with Fetal Alcohol Spectrum Disorder (FASD)

• Over 70,000 alcohol-related physical and sexual assaults every year

Treatment of John• The GP writes a referral for a very distraught John to the local

community addiction treatment service.

• The service has a six-week waiting list for assessment.

• Four weeks later, John receives a copy of a letter to his GP informing him that he is not eligible for assessment as he has significant depression, but that an urgent referral has been sent on to the mental health service.

• The mental health service also has a six-week waiting list for assessment.

• Four further weeks later John receives a copy of another letter to his GP informing him that he is not eligible for assessment as he has a significant alcohol problem

Treatment of John • John’s GP is exasperated and refers him to a local addiction

treatment programme run by an NGO.

• John completes the four week residential programme becoming abstinent from all drugs except cigarettes and feels a lot better and returns home feeling he’s “got this addiction thing beat”.

• Two weeks later John and Mary have a small argument and John relapses into heavy drinking and within a few days becomes severely depressed.

• Mary rings the NGO and is informed that John should come to the AA meeting there in three days time after which he could see a staff member. Mary is scared. She withdraws from John and cries a lot.

Treatment of John • John is angry and feeling totally hopeless goes on a

methamphetamine/alcohol bender. Two days into it he drives his car at high speed over the centre line colliding with an approaching car. Both John and the other driver are killed.

• John’s GP is shocked when he hears about the event. He feels helpless, and his opinion that it is a waste of time and money to try and treat alcoholics and drug addicts in the health service is reinforced.

• Mary is deeply distraught and blames herself. For the next six months she drinks heavily and subsequently delivers a highly irritable baby four weeks premature, who is diagnosed as having ADHD six years later.

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Treatment in the 2020s

• The GP refers a very grateful Mary to the practice nurse (PGDip) who sees her that afternoon.

• The distraught John and very grateful Mary are then seen together by the nurse at an appointment the next day.

• The nurse and GP meet briefly and John is subsequently prescribed naltrexone and invited to continue sessions with Mary and the nurse, which he takes up.

• John is reviewed four weeks later by his GP and is feeling a little better. His drinking has reduced considerably and his depression is improving. The nurse has added in NRT at John’s request.

Treatment in the 2020s

• Two weeks later John and Mary have a small argument and John relapses into heavy drinking and within a few days becomes severely depressed. Mary rings the practice nurse saying she is scared, because John seems so angry and desperate.

• The nurse consults the GP immediately and the GP rings the addiction specialist for urgent advice.

• John is admitted that afternoon to an addiction crisis bed for 48 hours.

• He is discharged back home on an antidepressant, his naltrexone doubled, a referral to a local NGO recovery course having been made, and with ongoing monitoring by the GP and practice nurse, who are continuing to see the pregnant Mary.

Treatment in the 2020s• John begins the two-year NGO recovery course which

incorporates an ongoing Facebook group for people who are “depressed and drinking too much” and over the next few months begins to feel considerably better as he sees how this addiction thing can be beaten.

• The GP completes an e-learning update on “alcoholic depression” and is considering doing further addiction study because he is enjoying treating people with addiction and co-existing problems so much.

• The practice nurse gives Mary information about the risk of FASD through any alcohol use in pregnancy and she immediately ceases drinking. Mary delivers a healthy baby at term six months later, whom John adores. John and Mary’s relationship deepens as does John’s commitment to abstinence, now from all drugs including tobacco.

“Change Takes Time”

• Having an epiphany is one thing; consolidating these new insights into ongoing real life behaviour is another

• Recovery from addiction is not so much a matter of changing one’s mind, but changing one’s brain

“Change takes time”

Tenzin Gyatso,

HH The 14th Dalai Lama of Tibet (1935–present)

“What is needed is that addicts alter

their whole pattern of living”

George Eman Vaillant, 1988 (1934-present)

Recovery

1. Recovery from a disorder (DSMIV, AA)PatientEarly remission/sustained emission/recoveryAbstinence (<10%)

2. Recovery of a worthwhile life (MHC)CitizenEmpowerment/normalization/strengths-basedFunctioning (>90%)

Addiction continuum

No Low risk Hazardous Problem Mild Moderate/severeuse use use use dependence dependence

ADDICTION

Focussed behavioural change aimed at low risk use

Lifestyle changeaimed at abstinence

ADDICTION APPRENTICESHIP

Four phases to recovery

Phase 1 Picking up the pieces from a failed lifestyleTREATMENT

Phase 2 Assembling a new lifestyleREHABILITION

Phase 3 Practising the new lifestyleAFTER-CARE

Phase 4 Living the new lifestyleSELF-MANAGEMENT

FailedFailedold lifestyleold lifestyle

1 2 3 4

Successful Successful new lifestylenew lifestyle

Clinical MxClinical Mx Self MxSelf Mx

Recovery is moving from an old addictive lifestyle to a new recovery lifestyle

People have varying degrees of moving to do

An effective new recovery lifestyle will be bigger than the old addictive lifestyle

Addiction TreatmentWhere are we going?

Primary Care Specialist Care

1990s

2020s

(20%)

(80%)

(80%)

(20%)

2x32x

What is the role of primary care in recovery from addiction?

1. Assessment

2. Acute treatment

3. Referral

4. Continuing care

Thinking of addiction as if it were asthma, diabetes or hypertension …

Addiction is very similar to these common chronic conditions

• <60% of people with diabetes and <40% of people with asthma or hypertension fully adhere to their medication schedules

• <30% of people with diabetes, asthma or hypertension adhere to prescribed diet and/or behavioural changes

• 50-70% of people with asthma or hypertension experience recurrence of symptoms each year requiring medical care to re-establish symptom remission

Answers to the three questions

1. Addiction is a learned, dehumanising brain disease featuring compulsive drug use

2. Recovery involves a re-learning process focused on practicing self-control within a new recovery lifestyle and an expanded life

3. Primary care is an excellent place for addiction recovery to begin and develop over time

RoleRoleAttitude Consumption Attitude Consumption Society Society

citizen proactive thoughtful civilized

consumer reactive passive consumer

addict psychopathic compulsive jungle