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Petros Levounis, MD, MA Chair, Department of Psychiatry

Rutgers New Jersey Medical School

ADDICTION MEDICINE ACADEMY Clearwater Beach, Florida

March 26, 2015

Bench to Bedside: From the Science to the Practice of

Addiction Medicine

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1. The Neurobiology of Addiction 2. Psychosocial Treatments 3. Pharmacological Treatments 4. Conclusions

Outline

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1 Neurobiology of Addiction

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2

4

~ 2000

The Fundamental Model

Biological

Psychological

Social

Use Brain Switch

Addiction

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Olsen and Levounis, Sober Siblings, 2008.

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2015

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1.  Continuum of Illness

2.  Motivational Circuitry

3.  Antireward Pathways

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Three Novel Areas

GAME 1 ?

A. A sure gain of $250.

B. 25% chance to gain $1,000, 75% chance to gain nothing.

Adapted from: Tversky and Kahneman, Science, 1981.

Reward Systems

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GAME 1 ?

A. A sure gain of $250. 84%

B. 25% chance to gain $1,000, 16% 75% chance to gain nothing.

Reward Systems

Adapted from: Tversky and Kahneman, Science, 1981.

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GAME 2 ?

A. A sure loss of $750.

B. 25% chance to lose nothing, 75% chance to lose $1,000.

Antireward Systems

Adapted from: Tversky and Kahneman, Science, 1981.

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GAME 2 ?

A. A sure loss of $750. 13%

B. 25% chance to lose nothing, 87% 75% chance to lose $1,000.

Adapted from: Tversky and Kahneman, Science, 1981.

Antireward Systems

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GAME 1

25% + 750 25% - 250 25% - 250 25% - 250

GAME 2

25% + 750 25% - 250 25% - 250 25% - 250

MATHEMATICS

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§  People avoid risks to ensure gains (even small gains).

§  People take risks (even big risks) to avoid definite losses.

§  Psychology trumps probability.

HUMAN NATURE

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2 Psychosocial Treatments

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1.  Psychoanalysis works for all treatable mental illness.

2.  Psychoanalysis does not work for addiction.

3.  Therefore, addiction cannot be treated.

1st Wave: Psychoanalysis

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The prototype, Synanon, was founded in California in 1958 to address heroin addiction.

The goal was to: Ø  break down defenses, Ø  bust through denial, and Ø  reshape the addict’s personality.

2nd Wave: Boot Camps

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The Frying Pan

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Volkow et al, J Neuroscience, 2001

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1.  Mutual Help Groups (12-step)

2.  Cognitive Behavioral Therapy

3.  Family Therapy

4.  Primary Care Services

5.  Mental Health Services

6.  Aftercare

3rd: The Kitchen Sink Approach

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Nunes, Selzer, Levounis, Davies, Substance Dependence and Co-Occurring Psychiatric Disorders, 2010.

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Mutual Help

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Attitudes and Perceptions

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PATIENTS

1.  Inner peace 2.  God 3.  Medical Services 4.  AA 5.  Housing 6.  Spirituality 7.  Outpatient Tx 8.  Community 9.  Gov’t Services 10. Trusting People 11.  Job

What Medicine Thinks

Patients Think 1.  Housing 2.  Outpatient Tx 3.  Medical Services 4.  Job 5.  Trusting People 6.  AA 7.  Inner Peace 8.  Community 9.  Gov’t Services 10. Spirituality 11. God

MEDICAL STAFF

1.  Housing 2.  Gov’t Services 3.  Medical Services 4.  Outpatient Tx 5.  Job 6.  Community 7.  Trusting People 8.  Inner peace 9.  God 10. Spirituality 11. AA

Goldfarb, Am J Drug Alcohol Abuse, 1996.

21 21 Levounis and Arnaout, Handbook of Motivation and Change: A Practical Guide for Clinicians, 2010. Graphic by Lukas Hassel.

4th: Motivational Interviewing (MI)

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“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lie our growth and our freedom.”

Viktor E. Frankl

5th: Mentalization

Frankl V, Man’s Search for Meaning, 1959.

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11.4

17.7

24.2 25

9.612.213.2

18.5

5.6

15.7

0

10

20

30

40

Only same-sex Mostly same-sex Equally both sexes Mostly other sex Only other sex

Women Men

% re

port

ing

any

subs

tanc

e us

e di

sord

ers

* ***

* Ref

*p<0.05, ***p<.001 based on logistic regression analysis adjusted for race, age, educational level, personal income, employment status, relationship status, health insurance status, geographic location, MSA, age at alcohol onset, and family history of AOD problems. Reference group was “heterosexual” group.

***

And Back to Psychodynamics…

Courtesy of Sean McCabe, PhD.

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3 Pharmacological

Treatments 25

Porter and Jick, N Engl J Med, January 10, 1980.

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The Prescription Opioids Epidemic: The Root of the Disaster

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Chronic Non-Cancer Pain

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Admissions: 1999 Primary non-heroin opioid admission rates (per 100,000)

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Admissions: 2001 Primary non-heroin opioid admission rates (per 100,000)

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Admissions: 2003 Primary non-heroin opioid admission rates (per 100,000)

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Admissions: 2005 Primary non-heroin opioid admission rates (per 100,000)

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Admissions: 2007 Primary non-heroin opioid admission rates (per 100,000)

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Admissions: 2009 Primary non-heroin opioid admission rates (per 100,000)

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12

0

1

2

3

4

5

6

7

8

9

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'70 '72 '74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06

Dea

th ra

te p

er 1

00,0

00

Heroin Cocaine

Unintentional Drug Poisoning Deaths United States: 1970 – 2007

Year

National Vital Statistics System, http://wonder.cdc.gov. 34

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Alcorn, The Lancet, June 5, 2014.

Unintentional Drug Poisoning Deaths United States: 1999 – 2011

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Ø  Agonists: Methadone Nicotine Replacement

Ø  Partial Agonists: Buprenorphine Varenicline

Ø  Antagonists: Naltrexone

Addiction Strategies

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Levounis and Herron, The Addiction Casebook, 2014.

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-10 -9 -8 -7 -6 -5 -4 0

10

20

30

40

50

60

70

80

90

100

% Efficacy

Log Dose of Opioid

Full Agonist (Methadone)

Partial Agonist (Buprenorphine)

Antagonist (Naloxone)

The Ceiling Effect

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Adapted from: Renner and Levounis, Office-Based Buprenorphine Treatment of Opioid Dependence, 2011.

4 Conclusions

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1.  Addiction hijacks the pleasure/reward and anti-reward pathways of the brain, as well as the person’s internal motivation.

2.  Cognitive Behavior Therapy, mutual help groups, and Motivational Interviewing revolutionized addiction treatment.

3.  In 2015, buprenorphine is the first line treatment of opioid use disorder.

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Thank you

NJMS.Rutgers.edu/Psychiatry

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