Addiction and Related Disorders

Table of Contents

Volume 42, Number 2

June 2010

Editors’ Introduction: Addiction and Related Disorders — David E. Smith, M.D., FASAM, FAACT

2010: U.S. Drug and Alcohol Policy, Looking Back and Moving Forward — Philip R. Lee, M.D.; Dorothy R. Lee & Paul Lee, M. Arch.

Parity and the Medicalization of Addiction Treatment — Ken Roy, M.D. & Michael Miller, M.D.

Health Care Equality and Parity for Treatment of Addictive Disease — David E. Smith, M.D., FASAM, FAACT; Dorothy R. Lee & Leigh Dickerson Davidson

Prescription Drug Abuse: An Epidemic Dilemma — Robert L. DuPont, M.D.

Food Addiction and Obesity: Evidence from Bench to Bedside — Yijun Liu, Ph.D.; Karen M. von Deneen, Ph.D.; Firas H. Kobeissy, Ph.D. & Mark S. Gold, M.D.

Sweet Preference, Sugar Addiction and the Familial History of Alcohol Dependence:  Shared Neural Pathways and Genes — Jeffrey L. Fortuna, Dr.P.H.

High Resolution Brain SPECT Imaging in a Clinical Substance Abuse Practice — Daniel G. Amen, M.D.

Buprenorphine in the Treatment of Opiate Dependence — Donald Wesson, M.D. & David E. Smith, M.D.

Mindfulness Training Modifies Cognitive, Affective, and Physiological Mechanisms

Implicated in Alcohol Dependence: Results of a Randomized Controlled Pilot Trial — Eric L. Garland, Ph.D., L.C.S.W.; Susan A. Gaylord, Ph.D.; Charlotte A. Boettiger, Ph.D. & Matthew O. Howard, Ph.D.

Managing Acute and Chronic Pain in a Substance Abuse Treatment Program for the  Addicted Individual Early in Recovery: A Current Controversy — Joseph D. Markowitz, M.D.; Elie M. Francis, M.D. & Cheryl Gonzales-Nolas, M.D.

Editor’s Note:The Evolution of Addiction Medicine and Its San Francisco Roots — David E. Smith, M.D., FASAM, FAACT

Western Behavioral Health and Addictive Disorders Conference Faculty

COVER ART — Butterfly by Michael Zimmerman

Abstracts

Addiction and Related Disorders

Editors’ Introduction: Addiction and Related Disorders — David E. Smith, M.D., FASAM, FAACT

2010: U.S. Drug and Alcohol Policy, Looking Back and Moving Forward — Philip R. Lee, M.D.; Dorothy R. Lee & Paul Lee, M. Arch.

Abstract—Since the early twentieth century, both moral perspectives and changing perceptions of the disease model of alcoholism and addiction have significantly influenced the formulation of U.S. domestic policy on drugs and alcohol. Some fluctuations have occurred in federal drug policy but overall a prohibitive, punitive approach has been emphasised. Racial and socioeconomic disparities have been exacerbated by the inequities of drug laws. Over the past 50 years, limited progress has been made in challenging and changing these unproductive policies. A great deal of progress has been made in research and treatment, and in the understanding of the process of recovery. For the upcoming generation to move policy in the direction shown to be effective by experienced addiction professionals will entail a wide spectrum of interdependent actions in substance abuse research, education, prevention and treatment, and continued cooperation between many stakeholders.

Keywords—addiction, alcoholism, federal policy, illegal drugs, recovery

Parity and the Medicalization of Addiction Treatment — Ken Roy, M.D. & Michael Miller, M.D.

Abstract—Parity, the idea that insurance coverage for the treatment of addiction should be on a par with insurance coverage for the treatment of other medical illnesses, is not a new idea, but the path to achieving “real parity” has been a long, hard and complex journey. Action by Congress to pass major parity legislation in 2008 was a huge step forward, but does not mean that parity has been achieved. Parity has required a paradigm shift in the understanding of addiction as a biological illness: many developments of science and policy changes by professional organizations and governmental entities have contributed to that paradigm shift. Access to adequate treatment for patients must acknowledge the paradigm shift reflected in parity as it has evolved to the current point: that this biological illness is widespread, that it is important that it be treated effectively, that appropriate third party payment for physician-provided or physician-supervised addiction treatment is critical for addiction medicine to become a part of the mainstream of our nation’s healthcare delivery system, and that medical specialty care provides the most effective and cost effective benefit to patients and therefore to our society.

Keywords—addiction, addiction medicine, ASAM, ABAM, substance abuse treatment, substance dependence treatment, public policy.

Health Care Equality and Parity for Treatment of Addictive Disease — David E. Smith, M.D., FASAM, FAACT; Dorothy R. Lee & Leigh Dickerson Davidson

Abstract—Substance abuse represents a significant underlying cause of the health issues faced in the United States, which severely impacts the nation’s health care system and economy. Recently legislated parity legislation mandates that benefits for addiction and mental health treatment be provided on an equal footing with those for treatment for physical health. Diversion and abuse of prescription medications is growing in young people, with much of the diversion occurring between family and friends. Addiction has been accepted by mainstream medicine as a brain disease, and is associated with many other medical disorders. Early intervention and treatment for addiction provides extraordinary cost-benefit outcomes. Additional training for addiction professionals will be necessary. Stigmatization of substance abusers continues to exist at the state and federal levels, although research during the past 10 years indicates that patient compliance and relapse rates for substance abusers are not significantly different than those for individuals with other chronic diseases, e.g. diabetes, hypertension, and cardiac issues. While parity for addiction treatment has become policy at the federal level, great challenges lie ahead in funding access, facilities, and training, as well as redirecting societal perceptions and legislated penalties.

Keywords—addiction, drug abuse, health care reform, parity, substance abuse

Prescription Drug Abuse: An Epidemic Dilemma — Robert L. DuPont, M.D.

Abstract—The nonmedical use of prescribed controlled substances has become a major public health problem. This article reviews the extent of prescription drug abuse reflected in drug overdose deaths, youth drug use and drug-impaired driving. Efforts to reduce illegal, nonmedical use of prescribed controlled drugs must be balanced so as not to interfere with appropriate medical use of these medicines. Future policy options include identifying and expanding leadership in the research and medical communities, creation of a national public education campaign, development of abuse-resistant drug formulas, increasing prescription drug monitoring programs and enforcement efforts, establishing effective drugged driving laws, and improving substance abuse treatment.

Keywords—drugs, impaired driving, prescriptions, public policy

Food Addiction and Obesity: Evidence from Bench to Bedside — Yijun Liu, Ph.D.; Karen M. von Deneen, Ph.D.; Firas H. Kobeissy, Ph.D. & Mark S. Gold, M.D.

Abstract—Obesity has become a major health problem and epidemic. However, much of the current debate has been fractious and etiologies of obesity have been attributed to eating behavior or fast food, personality issues, depression, addiction, or genetics. One of the interesting new hypotheses for epidemic obesity is food addiction, which is associated with both substance-related disorder and eating disorder. Accumulating evidences have shown that there are many shared neural and hormonal pathways as well as distinct differences that may help researchers find why certain individuals overeat and become obese. Functional neuroimaging studies have further revealed that good or great smelling, looking, tasting, and reinforcing food has characteristics similar to that of drugs of abuse. Many of the brain changes reported for hedonic eating and obesity are also seen in various forms of addictions. Most importantly, overeating and obesity may have an acquired drive like drug addiction with respect to motivation and incentive; craving, wanting, and liking occur after early and repeated exposures to stimuli. The acquired drive for great food and relative weakness of the satiety signal would cause an imbalance between the drive and hunger/reward centers in the brain and their regulation.

Keywords —body-weight control, brain imaging, food intake, reward, substance abuse

Sweet Preference, Sugar Addiction and the Familial History of Alcohol Dependence:  Shared Neural Pathways and Genes  — Jeffrey L. Fortuna, Dr.P.H.

Abstract—Contemporary research has shown that a high number of alcohol-dependent and other drug-dependent individuals have a sweet preference, specifically for foods with a high sucrose concentration. Moreover, both human and animal studies have demonstrated that in some brains the consumption of sugar-rich foods or drinks primes the release of euphoric endorphins and dopamine within the nucleus accumbens, in a manner similar to some drugs of abuse. The neurobiological pathways of drug and “sugar addiction” involve similar neural receptors, neurotransmitters, and hedonic regions in the brain. Craving, tolerance, withdrawal and sensitization have been documented in both human and animal studies. In addition, there appears to be cross sensitization between sugar addiction and narcotic dependence in some individuals. It has also been observed that the biological children of alcoholic parents, particularly alcoholic fathers, are at greater risk to have a strong sweet preference, and this may manifest in some with an eating disorder. In the last two decades research has noted that specific genes may underlie the sweet preference in alcohol- and drug-dependent individuals, as well as in biological children of paternal alcoholics. There also appears to be some common genetic markers between alcohol dependence, bulimia, and obesity, such as the A1 allele gene and the dopamine 2 receptor gene.

Keywords—A1 allele, cross sensitization, dopamine 2 receptor, nucleus accumbens, sucrose concentration, sweet preference

High Resolution Brain SPECT Imaging in a Clinical Substance Abuse Practice — Daniel G. Amen, M.D.

Abstract—Brain SPECT imaging is a nuclear medicine study that uses isotopes bound to neurospecific pharmaceuticals to evaluate regional cerebral blood flow (rCBF) and indirectly metabolic activity. With current available technology and knowledge SPECT has the potential to add important clinical information to benefit patient care in many different areas of a substance abuse practice. This article explores the clinical controversies and limitations of brain SPECT, plus seven ways it has the potential to be immediately useful in clinical substance abuse practice, including: adding valuable information to the prevention, evaluation, and treatment of substance abusers; helping clinicians ask better questions; helping them in making more complete diagnoses and preventing mistakes; evaluating underlying brain system pathology in individual patients; decreasing stigma and increasing compliance; visualizing effectiveness via follow-up evaluations; and encouraging the exploration of innovative and alternative treatments.

Keywords—brain injuries, brain system pathology, imaging, SPECT, substance abuse

Buprenorphine in the Treatment of Opiate Dependence — Donald Wesson, M.D. & David E. Smith, M.D.

Abstract—Compelling clinical evidence establishes that buprenorphine is similar to methadone in efficacy for opiate detoxification and maintenance but safer than methadone in an overdose situation. The Drug Abuse Treatment Act of 2000 (DATA 2000) enabled US physicians with additional training to prescribe buprenorphine to a limited number of opiate-dependent patients. The sublingual tablets Subutex^® (buprenorphine alone) and Suboxone^® (a combination of buprenorphine and naloxone) meet the specifications of DATA 2000. Suboxone is intended to discourage intravenously administration and has less abuse potential than buprenorphine alone. Suboxone is generally recommended for maintenance treatment except for women who are pregnant. Subutex is recommended in treatment of pregnant women. A buprenorphine opiate withdrawal syndrome can occur in newborns. Although intravenous buprenorphine abuse is a significant public health problem in some countries, buprenorphine alone or in combination with naloxone has less potential for abuse than heroin and some prescription opiates, such as oxycodone. Pharmacotherapy from physicians’ offices makes buprenorphine treatment acceptable to some opiate-dependent patients who would not accept treatment in traditional opiate-maintenance clinics. For reasons not adequately understood, some patients find discontinuation of buprenorphine following long-term use difficult. This article reviews the pharmacology of buprenorphine, summarizes evidence supporting the safety and efficacy of buprenorphine and provides clinical guidelines for treatment.

Keywords—DATA 2000, methadone, opiate agonist treatment, opiate receptors, review, treatment of opioid dependence

Mindfulness Training Modifies Cognitive, Affective, and Physiological Mechanisms Implicated in Alcohol Dependence: Results of a Randomized Controlled Pilot Trial — Eric L. Garland, Ph.D., L.C.S.W.; Susan A. Gaylord, Ph.D.; Charlotte A. Boettiger, Ph.D. & Matthew O. Howard, Ph.D.

Abstract—Mindfulness training may disrupt the risk chain of stress-precipitated alcohol relapse. In 2008, 53 alcohol-dependent adults (mean age = 40.3) recruited from a therapeutic community located in the urban southeastern U.S. were randomized to mindfulness training or a support group. Most participants were male (79.2%), African American (60.4%), and earned less than $20,000 annually (52.8%). Self-report measures, psychophysiological cue-reactivity, and alcohol attentional bias were analyzed via repeated measures ANOVA. Thirty-seven participants completed the interventions. Mindfulness training significantly reduced stress and thought suppression, increased physiological recovery from alcohol cues, and modulated alcohol attentional bias. Hence, mindfulness training appears to target key mechanisms implicated in alcohol dependence, and therefore may hold promise as an alternative treatment for stress-precipitated relapse among vulnerable members of society.

Keywords—alcohol dependence, attentional bias, heart-rate variability, mindfulness, stress, thought suppression

Managing Acute and Chronic Pain in a Substance Abuse Treatment Program for the Addicted Individual Early in Recovery: A Current Controversy — Joseph D. Markowitz, M.D.; Elie M. Francis, M.D. & Cheryl Gonzales-Nolas, M.D.

Abstract—Patients early in recovery from addictive disorders are in a tenuous position and when these individuals are stressed from acute or chronic pain they face even more challenges. Physicians are often conflicted by the desire to help the patient achieve pain control and maintain sobriety. While there have been a handful of studies examining patients in either active addiction with pain or with a more remote history of addiction with pain, there have been very few, if any, that look at treating patients during their addiction recovery process who suffer from pain. This article will examine the issue of whether it is ever appropriate to use opioid pain medications on such patients and, if so, what guidelines can be used to maximize the chances of a good outcome while minimizing the chances of causing a recurrence or exacerbation of addiction.

Keywords—addiction, early recovery, pain control, treatment program  

Editor’s Note:The Evolution of Addiction Medicine and Its San Francisco Roots — David E. Smith, M.D., FASAM, FAACT