From Alcohol Abuse to Dependency

NIH study finds chronic alcohol use shifts brain’s control of behavior

Chronic alcohol exposure leads to brain adaptations that shift behavior control away from an area of the brain involved in complex decision-making and toward a region associated with habit formation, according to a new study conducted in mice by scientists at the National Institutes of Health.

The finding provides a biological mechanism that helps to explain compulsive alcohol use and the progression to alcohol dependence. A report appears online in the Proceedings of the National Academy of Sciences (PNAS).

The brain’s prefrontal cortex is involved in decision-making and controlling emotion, while the dorsal striatum is thought to play a key role in motivation and habit formation. Past studies have shown that alcohol dependent individuals show problems with skills mediated by the prefrontal cortex such as impulse control. These same individuals often show exaggerated neural response in the dorsal striatum to alcohol-related cues.

To investigate whether changes in the dorsal striatum might account for these observations, researchers led by Andrew Holmes, Ph.D., in the Laboratory of Laboratory of Behavioral and Genomic Neuroscience at NIAAA, measured changes in the brains of mice that were chronically exposed to alcohol vapors.

He and his colleagues found profound changes in the dorsal striatum of these mice, including the expansion of neuronal dendrites, the branching projections of the nerve cell that conduct signals. Such changes are also seen with chronic exposure to drugs such as amphetamine. These structural changes were associated with changes in synaptic plasticity, the brain’s ability to change in response to experience, and reduced activity of endocannabinoid receptors, which are part of a signaling system that may play a role in sensation, mood, and memory.

“These findings give important insight into how excessive drinking affects learning and behavioral control at the neural level,” said Kenneth R. Warren, Ph.D., acting director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). “The shift to increased striatal control over behavior may be a critical step in the progression of alcoholism.”

“The changes we observed suggest that the manner in which the dorsal striatum signaled and adapted to environmental information has been altered by alcohol,” said senior author Dr. Andrew Holmes. “The findings imply that chronic drinking may set up a concerted set of adaptions in this key brain region that produce a bias for striatal control over behavior.”

Such changes could contribute to the emergence of habitual and compulsive patterns of behavior in alcohol abuse, and suggest that treatments designed to normalize striatal function may be an important approach for alcohol treatment.

Dr. Holmes and his colleagues add that their findings suggest that drug abuse doesn’t simply impair brain functions, but instead produces a complex set of adaptations that tamp down the function of some brain regions while dialing up the function of others.

Indeed, the researchers found that chronic alcohol actually improved the ability of mice to learn to make choices on a touchscreen.

“Improved performance on learning tasks that we know depend on the dorsolateral striatum is particularly interesting because it suggests that alcohol could prime the brain to favor other dorsal striatal behaviors – including things like habit formation, which may foster addictive patterns of behavior,” said Dr. Holmes.

The National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health, is the primary U.S. agency for conducting and supporting research on the causes, consequences, prevention, and treatment of alcohol abuse, alcoholism, and alcohol problems. NIAAA also disseminates research findings to general, professional, and academic audiences. Additional alcohol research information and publications are available athttp://www.niaaa.nih.gov.

About the National Institutes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visitwww.nih.gov.

NIH…Turning Discovery Into Health®

Reference

Chronic alcohol produces neuroadaptations to prime dorsal striatal learning. DePoy L, Daut R, Brigman JL, MacPherson K, Crowley N, Gunduz-Cinar O, Pickens CL, Cinar R, Saksida LM, Kunos G, Lovinger DM, Bussey TJ, Camp MC, Holmes A. PNAS. 2013 Aug 20. [Epub ahead of print]

Alternative Sentencing Option for Los Angeles and Orange County drug offenders

SereneCenter

FOR IMMEDIATE RELEASE:

CONTACT:
Andrew Martin
President
Serene Center, Inc.
Tel 562.366.3557 x.210
Fax 562.366.3586
andrew@serenecenter.com
www.serenecenter.com 

Serene Center and Twin Town Treatment Centers form alliance for Alternative Sentencing

Alternative sentencing is an effective method of diverting criminal violators who suffer from alcohol and drug dependence into programs designed for the rehabilitation and treatment of the alcoholic/addict instead of being interned in jail or prison settings. In California, a judge can issue a suspended sentence or defer adjudication and order the defendant to meet certain conditions such as completing an alcohol and drug treatment alternative sentencing program.

Serene Center and Twin Town Treatment Centers have worked together to create a specific program for defendants that would benefit from intensive outpatient treatment while residing in a highly structured and monitored living environment. This program is suitable for non-violent offenders that want assistance with their substance use disorder and are entirely willing to engage in the treatment process.

The alternative sentencing program includes a minimum of five months enrollment at the Twin Town Treatment Centers intensive outpatient program combined with Serene Center’s elevated sober living level of service which includes case management, mandatory drug testing every three days, medication monitoring, and brief intervention services.  Some of the costs associated with the program may be offset with health insurance.

ABOUT Serene Center Long Beach:   Serene Center Long Beach uniquely bridges the gap between primary treatment and customary sober living with a specialized 36 bed men’s transitional sober living home for alcoholics and addicts in early recovery.  We help people transition themselves to a better quality of life through certified therapy, education, and balanced center living guidance.

Press Kit Link

ABOUT Twin Town Treatment Centers:  Twin Town operates five freestanding outpatient treatment centers in Los Angeles and Orange County. The outpatient treatment centers are certified by the State of California and JCAHO accredited. Twin Town has a portfolio of over fifty third-party payer agreements and its payer mix is eighty-five percent HMO/ managed care. Through Twin Town’s Intensive Outpatient Treatment Services, clients are being successfully treated and most major insurance carriers and health maintenance organizations are paying the bill.

END

Does Science Show What 12 Steps Know?

Jarret Liotta

for National Geographic

Published August 9, 2013

Science has never revealed as much about addiction—potential genetic causes, influences, and triggers, and the resultant brain activity—or offered as many opportunities and methods for initial treatment as it does now.

Even so, the grassroots 12-step program remains the preferred prescription for achieving long-term sobriety.

Since the inception of Alcoholics Anonymous (A.A.)—the progenitor of 12-step programs—science has sometimes been at odds with the notion that laypeople can cure themselves.

Yet the success of the 12-step approach may ultimately be explained through medical science and psychology. Both offer substantive reasons for why it works.

Climbing the Steps to Recovery

The “miracle” of A.A. can be traced to the evening of June 10, 1935, when a struggling alcoholic named Bill Wilson, fighting to stay dry while on a business trip to Akron, Ohio, met with an apparently hopeless drinker named Bob Smith in order to quell his own thirst.

It had been suggested to Wilson, through a religious organization called the Oxford Group, that talking to wet drunks about his experiences and trying to help them get sober would, in turn, help him stay dry. Smith, once a respected physician in the community, was referred to him as someone at bottom, beyond help.

Their discussion sparked the insight that the best hope for sobriety was a daily reprieve from alcohol, which stood with the singular practice of helping others.

Over the next five years, a non-denominational program emerged that drew much of its spiritual doctrine from Christian practices. It embodied an action plan in the form of 12 “steps” that are essentially guidelines for right living, including taking a personal inventory of one’s strengths and shortcomings, making restitution for past wrongs, and helping others find sobriety.

A.A. reports that more than two million members worldwide currently stay sober by regularly attending meetings and implementing these steps.

In recent decades, the 12 steps have been applied to other addictions—everything from drugs, food, and other substances to various compulsive behaviors around gambling or sex.

Psychic Solution

Most addicts receive less than 30 days of inpatient treatment. But they must also accept that they need ongoing outside help.

The 12-step approach, said Paul Gallant, an interventionist with 27 years of sobriety, is “so popular with treatment centers because it’s proven to work. When a person completes treatment, they have a place to go.

“Self-knowledge is not a sufficient treatment for alcoholism,” continued Gallant. “I’ve worked with people who have had years and years of psychotherapy and intensive analysis, but it’s brought them no closer to ongoing abstinence.”

However, experiencing what Gallant called a “psychic change,” which in the 12-step world is linked to the marvel of a “spiritual awakening,” often results in a distinct personality and behavioral transformation that leads to long-term sobriety.

“The not-drinking is really just a part of it,” Gallant said. “It’s not drinking and changing as a person. That psychic change needs to come from a program of spiritual development, and so far the greatest success has been Alcoholics Anonymous.”

Community Spirit(ual)

Established treatment facilities like Sierra Tucson offer everything from traditional medicine to such alternative approaches as equine therapy and healing circles.

According to Nia Sipp, staff psychiatrist with Sierra Tucson, the goal is not just removing the substance or behavior but also facilitating self-reflection and creating social systems. “Oftentimes people feel that it’s about God and other things,” Sipp said. But she believes that the A.A. concept is more about “the spirit of community.”

Rev. Jack Abel, director of spiritual care at Caron Treatment Centers, agreed. “When we say spirituality, we’re talking about connection. People who are addicted become disconnected. And spirituality, as it’s emphasized in the program of the 12 steps, is profoundly reconnecting.”

According to Marvin Seppala, chief medical officer at Hazelden and sober 37 years, attending 12-step meetings does more than give an addict warm, fuzzy feelings.

The unconscious neurological pull of addiction undermines healthy survival drives, causing individuals to make disastrous choices, he said. “People will regularly risk their lives—risk everything—to continue use of a substance.”

Addicts don’t want to engage in these behaviors, but they can’t control themselves. “The only way to truly treat it is with something more powerful,” he said—something, like the 12 steps, that can change patterns in the brain.

Left Brain, Right Brain

Andrew Newberg studies neurotheology—the science of how spiritual practices affect the brain.

He avoids theological opinions, noting that the positive mental and emotional effects that might come from believing in God are real to the individual. “Irrespective of whether God truly exists or not,” Newberg said, “the brain is less interested in the accuracy of reality than the adaptability of how we respond.”

Bill Wilson had a famous “white light” experience in a hospital room, where he was recovering from what would be his last alcoholic bender. He claimed it was a spiritual awakening that not only changed his outlook but also removed his desire to drink.

Newberg said that “large-scale, existential-type crises” such as Wilson’s can bring instant changes to the brain. New neuronal pathways are activated or reactivated. This instant rewiring, Newberg said, generates a sudden and intense “aha” moment.

Newberg speculates that such an event may occur because of differences between the brain’s left and right hemispheres, which approach problems differently. The left side struggles to work through a problem from an analytical, black-and-white perspective.

But the right side may suddenly kick in and apply a very different, more holistic solution. In such a moment, the neurons of the brain are immediately realigned, spurred on by intense emotion relating to the crisis.

This same experience, sometimes described as a “eureka!” moment—or a cognitive insight phenomenon—is often referenced in relation to creative breakthroughs.

One 2008 study found that when the left side of the person’s brain dwells on a problem, it produces an excessive amount of obstructive gamma waves. The more the person ruminates on the problem, the harder it becomes to solve.

Conversely, when concentration is relaxed—or as Newberg said, when the person manages to quiet the left side of the brain and involve the right—the sudden appearance of new answers and insights can feel profound.

Neglected Realm

David Shurtleff, acting deputy director of the National Institute on Drug Abuse (NIDA), described addiction as a mainstream medical problem suffering from a lack of coordinated efforts.

The first four years of medical school routinely provide doctors with only a few hours of instruction on addiction. Shurtleff said his agency would like to see more training for primary care physicians, including equipping them with a standardized assessment to diagnose addiction. “We do the best we can,” he said, “but it’s an uphill fight.”

Meanwhile, brain science marches on. Understanding of addiction at the cellular level continues to yield revelations that seem to cast light on why 12-step meetings succeed.

Power of Dopamine Receptors

D2 dopamine receptors connect dopamine, a key neurotransmitter, to neurons. When these receptors are not functioning—or there are too few of them available to connect the dopamine to neurons—memory, mood, and thinking may all be impaired.

A shortage of D2 receptors, some researchers surmise, could predispose a person to addiction.

Nora Volkow, NIDA’s director, led two studies that involved artificially increasing the number of D2 receptors in rats by administering adenoviral vectors directly into their brains. Viral vectors transmit their genetic material and makeup into foreign cells, in this case increasing the number of D2 receptors in the new cells to match their own.

In one study involving rats and alcohol, the increased number of D2 receptors led the rodents to consume less alcohol, compared with their baseline intake.

In the other study, the D2-receptor increase caused rats to significantly reduce their intake of cocaine.

Michael Nader, a researcher at Wake Forest School of Medicine, is investigating ways to raise D2-receptor levels naturally. One experiment he helped conduct focused on five separate groups of four monkeys. Each had been self-administering cocaine to the point of habit and were then deprived of the drug for an eight-month period. To create a picture of D2-receptor availability, the monkeys were given a radioactive tracer that competes with dopamine for receptors.

The monkeys were then randomly put in social groups of four and given the opportunity to self-administer the drug again.

Positron emission tomography (PET) imaging of the monkeys over time showed fluctuations in dopamine levels, which allowed the researchers to estimate the changing numbers of available D2 receptors. After only three months, the socially dominant monkeys in each group had naturally increased their numbers of D2 receptors.

There was no increase in the subordinate monkeys. Further, the subordinate monkeys reverted to using cocaine at much higher levels than the dominant monkeys.

“There is an interesting relationship between D2-receptor numbers and vulnerability to drug addiction,” Nader said. “It appears that individuals with low D2 measures are more vulnerable compared to individuals with high D2-receptor numbers.”

Why did the socially dominant monkeys show D2-receptor increases? “One hypothesis,” Nader said, “is environmental enrichment.” For the monkeys, it seems, being dominant was the enriching trigger.

One physiological consequence of involvement in 12-step meetings, therefore, could be an increase in the natural production of D2 receptors. “That’s another whole area to be studied beyond the animal world,” Shurtleff said.

Need for Attachment

Philip Flores, author of Addiction as an Attachment Disorder, said the human need for social interaction is a physiological one, linked to the well-being of the nervous system.

When someone becomes addicted, he said, mechanisms for healthy attachment are “hijacked,” resulting in dependence on addictive substances or behaviors.

Some believe that addicts, even before their disease kicks in, struggle with knowing how to form emotional bonds that connect them to other people. Co-occurring disorders, such as depression and anxiety, make it even harder to build those essential emotional attachments.

“We, as social mammals, cannot regulate our central nervous systems by ourselves,” Flores said. “We need other people to do that.”

While it’s commonly understood that early childhood attachments to parents and family are necessary for healthy development, Flores maintains that emotional attachments remain necessary throughout adulthood.

This is where a 12-step program becomes valuable.

It’s not enough, Flores said, to remove the addiction, which in itself has become an object of unhealthy emotional and physical attachment. To achieve long-term well-being, addicts need opportunities for forging healthy emotional attachments.

“What A.A. does on the basic level is what good psychotherapy does,” Flores said. It provides “a community for people to break their isolation and to start to connect on an emotional level with other people.”

Helping Heals

Lee Ann Kaskutas, a scientist with the Alcohol Research Group, has faced skepticism from colleagues for studying A.A., in part because of the numerous spiritual references that go with the 12-step program. It puts A.A. on “the fringe” in the minds of many scientists, Kaskutas said.

Kaskutas, a self-proclaimed atheist, said that the 12 steps bear fruit regardless of one’s spiritual beliefs. “If you don’t believe in God, the way it weasels in is in the help and behaviors that the 12-step group inculcates.”

Helping others, Kaskutas said, “is the internal combustion engine of A.A. I think that is the connection to spirituality.”

People feel better about themselves after helping someone else, Kaskutas said. “So it’s reinforcing—when you help somebody, I think your brain chemistry changes.”

—Follow Jarret Liotta on Facebook.

Pain Management and Addiction

Pain Management and Addiction

Studies indicate that chronic pain and substance use disorders (SUDs) frequently co-occur (Chelminski et al., 2005; Rosenblum et al., 2003; Savage, Kirsh, & Passik, 2008); as such, addiction counselors who are knowledgeable about pain issues can provide better care for clients challenged by the need for assistance with pain control as well as substance abuse or dependence. This issue of the ATTC Messenger provides a basic overview of how pain and addiction can intersect and overlap. Much of the information derives from SAMHSA’s TIP 54 “Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders .”Comorbid chronic pain and SUDs require collaborative care including behavioral health, primary care, and often physical or occupational therapy and a consultation with pharmacy. Contributing to significant health care costs and misuse of services, these conditions will certainly demand that primary care and behavioral health rethink the current silos in which they operate as payment and systems reform unfold.

Chronic Pain

Chronic pain and addiction have many shared neurophysiological patterns. Most chronic pain involves abnormal neural processing. Similarly, addiction results when normal neural processes, primarily in the brain’s memory, reward, and stress systems, are altered into dysfunctional patterns. A full understanding of each condition is still emerging, and there is much to be learned about these conditions and their etiology, course of development, patterns of severity, interactions, and response to treatment.

Chronic pain and addiction are not static conditions. Both fluctuate in intensity over time and under different circumstances often require ongoing management. Treatment for one condition can support or conflict with treatment for the other; a medication that may be appropriately prescribed for a particular chronic pain condition may be inappropriate given the patient’s substance use history.

Chronic pain and substance use disorders (SUDs) also have similar physical, social, emotional, and economic effects on health and well being (Green, Baker, Smith, & Sato, 2003). Patients with one or both of these conditions may report insomnia, depression, impaired functioning, and other symptoms. Effective chronic pain management in patients with or in recovery from SUDs must address both conditions simultaneously (Trafton, Oliva, Horst, Minkel, & Humphreys, 2004).

Pain and responses to it are shaped by culture, temperament, psychological state, memory, cognition, beliefs and expectations, co-occurring health conditions, gender, age, and other factors. Because pain is both a sensory and an emotional experience, it is by nature subjective. Pain may be acute (e.g., postoperative pain), acute intermittent (e.g., migraine headache, pain caused by sickle cell disease), or chronic (persistent pain that may or may not have a known etiology). These categories are not mutually exclusive; for example, acute pain may be superimposed on chronic pain.

 

Continued pain can trigger emotional responses, including sleeplessness, anxiety, and depressive symptoms, which in turn produce more pain. Such feedback cycles may continue to cause pain after the physiological causes have been addressed. Several studies show that the outcome of pain treatment is worse in the presence of depression, or when depression does not respond to treatment, and that the future course of pain syndromes can be, in part, predicted by emotional status (Center for Substance Abuse Treatment, 2012). Physical inactivity and a lack of engagement with life may also lead to increased levels of anxiety, depression, and an increased risk for suicidal ideation; this may in turn lead a person to use substances in an attempt to treat themselves.

 

The Cycle of Chronic Pain and Addiction

If use of a prescription pain medication (i.e. opioid analgesics) results in physical dependence, the person may experience increased pain when the substance is absent along with withdrawal symptoms (e.g., anxiety, nausea, cramps, insomnia). Withdrawal symptoms may lead to an increase in symptoms of depression and an increase in the potential risk for suicide. Ingesting more of the drug that caused the dependence relieves many of these symptoms. A similar situation may occur if the drug is one that elicits rebound symptoms. For example, ergot relieves migraines, but excessive use leads to rebound headaches that are more persistent and treatment resistant than were the original headaches.

In some people, a cycle develops in which pain or distress elicits severe preoccupation with the substance that previously provided relief. This cycle—seeking pain relief, experiencing relief, and then having pain recur—can be very difficult to break, even in the person without an addiction, and the development of addiction markedly exacerbates the difficulty.

Addiction to prescription pain medication is widely misunderstood and part of working with chronic pain sufferers is helping to educate them. Below are two common misunderstandings that your clients may hold:

1. “If I need higher doses or have withdrawal symptoms when I quit, I’m addicted.”

Many people mistakenly use the term “addiction” to refer to physical dependence. That includes doctors. “Probably not a week goes by that I don’t hear from a doctor who wants me to see their patient because they think they’re addicted, but really they’re just physically dependent,”said Scott Fishman, MD, professor of anesthesiology and chief of the division of pain medicine at the University of California, Davis School of Medicine, interviewed for an article on WebMD. In the same article, Susan Weiss, PhD, chief of the science policy branch at the National Institute on Drug Abuse notes, “Physical dependence, which can include tolerance and withdrawal, is different. It’s a part of addiction but it can happen without someone being addicted.” She adds that if people have withdrawal symptoms when they stop taking their pain medication, “it means that they need to be under a doctor’s care to stop taking the drugs, but not necessarily that they’re addicted”(Hitti, 2011).

2. “Everyone gets addicted to pain drugs if they take them long enough.”

“The vast majority of people, when prescribed these medications, use them correctly without developing addiction,” said Marvin Seppala, MD, chief medical officer at the Hazelden Foundation (Hitti, 2011).

Dr. Weiss elaborates more about the complexities, commenting, “I think where it gets really complicated is when you’ve got somebody that’s in chronic pain and they wind up needing higher and higher doses, and you don’t know if this is a sign that they’re developing problems of addiction because something is really happening in their brain that’s … getting them more compulsively involved in taking the drug, or if their pain is getting worse because their disease is getting worse, or because they’re developing tolerance to the painkiller”(Hitti, 2011).

Primary Care Issues in Treating Pain in SUD Patients

Providing pain control for the 5% to 17% of the U.S. population with a substance abuse disorder presents primary care physicians with unique challenges that may be helpful for addiction counselors to understand. These include:

 When these individuals experience pain, they are less likely to receive adequate pain management than the general population.

 Inadequate pain relief is a significant risk factor for relapse.

 Distinguishing between patients who are seeking pain relief and those seeking drugs for the euphoric effects and identifying tolerance and physiologic. Dependence is critical to effective care and pain control. Comorbid psychiatric and medical illnesses may complicate effective pain management (Prater, Zylstra , Miller, 2002).

 

Further, most doctors do not have much training in addiction, or in pain management for that matter. Most addiction counselors do not have much training in pain management. Working together may be key for successfully treating patients.

SAMHSA’s TIP 54 (as noted previously) presents a consensus panel’s recommended strategy for treating chronic pain in adults who have or are in recovery from a substance use disorder.

 

Collateral information is an important part of the assessment of pain treatment in primary care, as it is with addiction treatment. Clinicians should communicate with families, pharmacists, addictions counselors and other clinicians, after the patient has given consent. If the patient declines to give consent, prolonged treatment with controlled pain medications may be contraindicated. Collateral information also helps protect the patient from misusing medications.

Addiction counselors should keep in mind that several factors may complicate a physician’s assessment of pain levels:

 

 Clinicians are especially likely to underestimate—and, therefore, to undertreat—pain and disability in women, the elderly, minorities, people of low economic status, and people with SUDs (Green, Baker, Smith, & Sato, 2003; Rupp & Delaney, 2004).

 Some patients with histories of SUDs may over report their pain experience if they are afraid that they will be under-medicated or that their symptoms will not be taken seriously.

 Others may under report their pain experience if they are afraid they will be prescribed medications that will cause them to relapse.

 Some patients may exaggerate pain and disability to obtain opioids for reasons other than pain control.

 

Each of these challenges may be addressed with clinic policies and procedures for comprehensive and regular assessment, improved provider patient communication, and collaborative care protocols allowing the PC providers to interact with the behavioral health staff and counselors. Clinicians must assess all patients who have chronic pain at regular intervals because treatment needs can change. For example, a patient may develop tolerance to a particular opioid, or the underlying disease condition may change or worsen.

In a recovering individual, the fear of experiencing withdrawal can be a substantial block to successful discontinuation of medication when it is no longer needed for pain control. Successful management of these concerns may be accomplished by slowly tapering medications over several days under close supervision as well as working with a pain and/or addiction medicine specialist who is able to suggest alternate pharmacotherapy that isn’t addictive to help manage the withdrawal. In certain cases, short-term admission to a detoxification unit may be necessary.

Safe Treatment of Pain for the Recovering Addict

Recovering alcoholics and addicts in pain can be treated safely. Below are some guidelines from “Addiction and the Treatment of Pain” by Peggy Ziegler published in Substance Use and Misuse:

Acute pain (postoperative pain, following trauma, after dental work)

 Patient-controlled analgesia is generally not recommended for persons recovering from addictive disorders. Whenever possible, opioid medications should be held and administered by a trusted other person to remove the potential for dosage escalation.

 Many recovering persons have increased tolerance to the effects of the opioid drugs and may require higher than average doses for appropriate effect (Savage, 2003). It is best to administer the drugs on a timed schedule rather than as needed or “prn.” This removes decision-making from the patient about when the next dose is needed.

 As soon as possible, the patient should be converted to a non-opioid regimen such as an NSAID, combined with heat, ice, physical therapy, and/or other complementary interventions.

 During a bout with acute pain, the recovering person needs increased recovery support. If possible, daily contact with sponsor and others in recovery can assist the patient to

talk about cravings, feelings of sadness, anger, grief and loss, or fears. Strengthening the support system may make all the difference in preventing relapse. The abstinent addict or alcoholic who does not have an ongoing program of recovery is at high risk of relapse when exposed to opioid pain medications, sedative muscle relaxants, etc.

 

Chronic pain presents different and perhaps more challenging management situations, which can best be addressed within a collaborative care model.

 A plan for pain management starts with a thorough assessment of the patient’s physical and emotional health and recovery. This usually involves in-depth discussion and examination of the patient; a review of records from previous care providers; collateral contacts with significant persons in the patient’s life and current health care providers; urine toxicology with broad range of testing for substances including synthetic opioids, agonist/antagonist opioids, short-acting benzodiazepines and barbiturates, and over-the-counter substances such as diphenhydramine, ephedrine, phenylpropanolamine, etc.

 The drug use history needs to explore alcohol use patterns, use of illicit drugs, prescription and over-the-counter drugs, and use of herbal preparations and food supplements including “energy drinks,” and “natural sleep aids.”

 For the recovering person suffering from chronic pain who is not currently taking opioids or sedatives, every effort should be made to develop a pain management plan that effectively controls the pain without these substances.

 A structured, written protocol provides a framework that decreases anxiety, increases the patient’s sense of active participation in and control of his or her own care, and gives the family and other caregivers a map to follow. Using a protocol greatly decreases the likelihood that the patient will end up in the Emergency Department being treated by providers unfamiliar with the clinical situation and inexperienced in treating recovering addicts.

 In addition to standard pain medications, such as nonsteroidal anti-inflammatory agents (NSAIDS), acetaminophen, and migraine-specific drugs, a variety of novel approaches to pain management may benefit some—anticonvulsants (McQuay et al., 1995) and low-dose tricyclics are examples (Fields, 1994).

 Complementary approaches, in particular acupuncture, biofeedback, and hypnosis, are also very important pieces of the comprehensive pain management plan (Andersson and Lundeberg, 1995).

 Outpatient group therapy with others living with chronic pain, led by a specially trained therapist, can combine cognitive behavioral techniques and supportive interventions to help restore function and improve outlook and overall attitude (Flor et al., 1992).

 Many chronic pain patients recovering from addiction have additional psychiatric disorders which also require treatment if the pain management strategy is to be successful. Common comorbidities include depression, anxiety disorders including post- traumatic stress disorder, somatoform disorders, personality disorders and adjustment disorders, which may or may not be directly related to the pain syndrome. Commonly the pain is found to have both physical and psychological components, and aggressive treatment of co-morbid psychiatric illness can decrease the severity of the pain, improve the patient’s adherence to the pain management strategy, and improve the patient’s participation in and benefit from his or her addiction recovery program (Grinstead and Gorski, 1999; Ciccone et al., 2000; Rosenblum et al., 2003; Toomey et al., 1995).

 When the pain is not responsive to such approaches, and opioids are required to control the patient’s pain, it is essential that a structured plan be in place and a clear written agreement be developed, reviewed by all parties, and signed by the patient, the physician or physicians involved in the treatment, participating family members, counselors, physical therapists, acupuncturists, etc. One physician should prescribe all controlled drugs, and with one pharmacy filling all prescriptions.

 As with acute pain, dealing with chronic pain involves ongoing recovery support, including the following, which addiction counselors can help their clients obtain:

 

Clearly, in dealing with the complexities outlined above, providers who adhere to a collaborative care model are going to be much more effective and provide better care for their patients. Without a team approach, patients may be exposed to inconsistent, duplicative, or even contraindicated, care.

Treating Dependence on Prescription Painkillers: What Works?

What happens if a person becomes dependent upon painkillers—how is that best treated? “The “standard treatment” for prescription opioid dependence is evolving, and I can’t say that there is a single current standard at this time,” says Roger Weiss, of Harvard Medical School in Boston, MA. Weiss was the lead author of the first—and so far only—large-scale study of the treatment of prescription opioid addiction, which posed as many questions as it answered (Holmes, 2012).

At present, many patients addicted to opioids who seek treatment are tapered off the drugs and given behavioral treatment alone, or are otherwise maintained on buprenorphine or methadone. “In our study, even those who were maintained on buprenorphine for 12 weeks had successful outcomes in only approximately half of the cases”, says Weiss, while behavioral treatment after tapering off opioid drugs “did not result in good outcomes. Most patients who tapered off of buprenorphine did return to opioid use,” Weiss explains. “I believe that this shows that for many such patients, ongoing pharmacotherapy may be highly beneficial in sustaining recovery. We are currently conducting a longer-term follow up study which should give us greater insight into the types of treatments that would be necessary to sustain longer-term recovery.” One such option could be naltrexone, an opioid receptor antagonist. Although poor adherence to oral naltrexone has limited its success in the past, an injectable extended release formulation is available. “We will see what role long-lasting injectable naltrexone has in the treatment of this population,” Weiss affirms (Holmes, 2012).

“I think that recovery from prescription opioid dependence is likely best achieved through a combination of pharmacotherapy and counseling,” concludes Weiss; “determining the optimal combination of these two treatment approaches is an evolving field.”(Holmes, 2012).

Addiction Counselors: A Vital Part of the Treatment Team

Chronic pain management is often complex and time consuming. The effectiveness of multiple interventions is augmented when all medical and behavioral healthcare professionals involved collaborate as a team (Sanders, Harden, & Vicente, 2005). Addiction specialists, in particular, can make significant contributions to the management of chronic pain in patients who have SUDs. They can: put safeguards in place to help patients take opioids appropriately; reinforce behavioral and self-care components of pain management; work with patients to reduce stress; assess patients’ recovery support systems, and identify relapse. The more complicated the case, the more beneficial a team approach becomes.

Sean Mackey, MD, PhD, Chief of the Pain Management Division at Stanford University and Associate Professor of Anesthesia and Pain Management states “A multidisciplinary approach is needed to treat patients in pain who have substance abuse issues.”

When treating patients with both chronic pain and a substance abuse disorder, Dr. Mackey advises making sure that they are receiving psychological counseling, either in a group or individually. “Many treatments we use in substance abuse overlap with chronic pain treatment—the psychological and behavioral skills are the same,” he says. (Vimont, 2011)

Author: Wendy Hausotter, MPH – Research Associate, Northwest ATTC.

Sources:

Center for Substance Abuse Treatment. Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2012. (Treatment Improvement Protocol (TIP) Series, No. 54.) 1.

Chelminski PR, Ives TJ, Felix KM, Prakken SD, Miller TM, Perhac JS, et al. (2005). A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Services Research. 5(1):3.

Green CR, Baker TA, Smith EM, Sato Y. (2003). The effect of race in older adults presenting for chronic pain management: A comparative study of black and white Americans. Journal of Pain. 4(2):82–90.

Hitti ,M. Prescription Painkiller Addiction: 7 Myths. WebMD Feature 2011. Retrieved June 3, 2013 from http://www.webmd.com/pain-management/features/prescription-painkiller-addiction-7-myths

Holmes, D. (2012), Prescription drug addiction: the treatment challenge. The Lancet, 379 (9810), 17 – 18.

Prater, C. Zylstra, R. & Miller, K. (2002). Successful Pain Management for the Recovering Addicted Patient. Prim Care Companion J Clin Psychiatry. 4(4): 125–131.

Rosenblum A, Joseph H, Fong C, Kipnis S, Cleland C, & Portenoy R. (2003). Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. Journal of the American Medical Association. 289(18):2370–2378.

Rupp T, Delaney KA. (2004). Inadequate analgesia in emergency medicine. Annals of Emergency Medicine. 43(4):494–503.

Sanders, SH, Harden, RN & Vicente, PJ (2005). Evidence-based clinical practice guidelines for interdisciplinary rehabilitation of chronic nonmalignant pain syndrome patients. Pain Practice, 5(4):303–315.

Savage SR, Kirsh KL, Passik SD. (2008). Challenges in using opioids to treat pain in persons with substance use disorders. Addiction Science and Clinical Practice. 4(2): 4–25.

Trafton, J, Oliva, EM, Horst, DA, Minkel JD, Humphreys K. (2004). Treatment needs associated with pain in substance use disorder patients: Implications for concurrent treatment. Drug and Alcohol Dependence. 73:23–31.

Vimnt, C. (2011) Challenges of Treating Chronic Pain in People with Opioid Dependence. The Partnership at DrugFree.org. Retrieved online June 5, 2013 from http://www.drugfree.org/join-together/addiction/challenges-of-treating-chronic-pain-in-people-with-opioid-dependence.

Ziegler, P. (2005) Addiction and the Treatment of Pain. Substance Use & Misuse, 40:1945–1954. 10 11

(optional) ADDITIONAL RESOURCES

American Academy of Pain Medicine American Board of Pain Medicine

American Pain Society (APS) American Society of Addiction Medicine (ASAM)

American Society for Pain Management Nursing (ASPMN)

ASPMN Position Statement: Pain Management in Patients with Addictive Disease

C.A.R.E.S. Alliance Definitions Related to the Use of Opioids for the Treatment of Pain (APS) International Association for the Study of Pain

International Association for the Study of Pain: Clinical Updates Pain and Addiction (ASAM)

Rights and Responsibilities of Health Care Professionals in the Use of Opioids for the Treatment of Pain (ASAM)

TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction (SAMHSA)

TIP 54: Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders (SAMHSA)

Prescription Drugs and Addiction

CDC Vital Signs Report, “Prescription Painkiller Overdoses: Use and Abuse of Methadone as a Painkiller”

NIDA: Prescription Drugs: Abuse and Addiction

Office of National Drug Control Policy: Prescription Drug Abuse Prevention Plan

Pain Management and Addiction Medicine, lecture by Dr. Russell Portenoy, Chairman, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center and professor of Neurology and Anesthesiology, Albert Einstein College of Medicine

SAMHSA: “Addiction by Prescription,” Recovery Month Webcast

SAMHSA-HRSA Center for Integrated Health Solutions: Pain Management

Other Resources

ATTC Webinar: Chronic Pain: An Integrated Care Approach March 6, 2012 Presented by Karl Haake, Richard Lillard, and Katherine Friedebach

 

CME modules on pain management from NIDA Med http://www.drugabuse.gov/nidamed/etools?utm_source=National&utm_medium=Web&utm_content=NIDAMED&utm_campaign=NIDAMED

Chronic Opioid Therapy Safety Guideline for Patients With Chronic Non-Cancer Pain

Cognitive Therapy for Pain by Beverly E. Thorn is a paper that specifically targets the cognitive psychological processes (pain-related thoughts, attitudes, and beliefs) shown to be important predictors of satisfactory adjustment to chronic painful conditions.

PainEDU is a website that provides numerous resources and information on managing chronic pain. Resources include a pocket guide to pain management, a client workbook and information on cross-cultural pain management.

Physicians for Responsible Opioid Prescribing provides physician educational materials to reduce morbidity and mortality resulting from prescribing of opioids and to promote cautious, safe and responsible opioid prescribing practices.

The Center for Practical Bioethics-Pain Action Initiative: A National Strategy (PAINS) shares podcasts, reports, and information from various national efforts to improve the treatment of individuals with chronic pain

The ECHO project done through the University of New Mexico is a telehealth project that allows providers from all over the country to get assistance for difficult pain management cases through virtual consultation with a pain management team at the UNM. This is a great resource for those practicing in rural areas without pain specialists for referral.

California Fines Kaiser $4M Over Violations of Mental Health Laws

Wednesday, June 26, 2013

Kaiser_Mailing

On Tuesday, the California Department of Managed Health Care fined the Kaiser Foundation Health Plan $4 million for failing to correct violations of mental health laws, Modern Healthcare reports.

The health plan is part of Kaiser Permanente’s integrated health care delivery system (Carlson, Modern Healthcare, 6/25).

The fine is the second-largest in DMHC’s history (Craft, Sacramento Bee, 6/26).

Background

In March, DMHC issued a report finding that Kaiser mismanaged its mental health care services.

The report was released as part of a routine mental and physical health services survey conducted every three years.

The report found that Kaiser had:

  • Made patients wait excessively long periods between appointments; and
  • Offered patients inaccurate information that could have dissuaded them from seeking long-term individual therapy.

According to the report, Kaiser provided information sheets stating that individual counseling services “will not be a Kaiser-covered benefit and will not be paid for by Kaiser.” DMHC said that such statements “are in error because the [p]lan is required to provide coverage for serious mental illnesses under the same terms and conditions as medical conditions” (California Healthline, 3/20).

Details of DMHC Announcement

On Tuesday, DMHC said that the fine stems from Kaiser’s failure to:

  • Reduce wait times;
  • Fix inaccurate information; and
  • Properly record tracking data for mental health appointments.

The agency has scheduled a follow-up inspection for October (Modern Healthcare, 6/25).

Kaiser’s Response

Following DMHC’s announcement, Kaiser officials said they plan to challenge the penalty for being too high.

John Nelson, a vice president at Kaiser, said the fine is “unwarranted and excessive.”

Nelson also said that the majority of first-time therapist appointments are booked within 10 business days and that Kaiser has hired additional staff to reduce wait times (Sacramento Bee, 6/26).

He said that each problem identified by DMHC has “already been corrected, or is very far along toward resolution” (Robertson, Sacramento Business Journal, 6/25).

Broadcast Coverage

Headlines and links to broadcast coverage of the Kaiser fine are provided below.

Read more: http://www.californiahealthline.org/articles/2013/6/26/california-fines-kaiser-4m-over-violations-of-mental-health-laws.aspx#ixzz2XKzpuXSa

Brain Scans Can Predict Which Alcoholics Are Most Likely to Relapse

By Maia Szalavitz May 02, 2013

131953873

Getty Images/Flickr RF / Getty Images/Flickr RF

For any addiction, external cues and stress can trigger cravings that are hard to resist, and the latest research points to an area of the brain that might be responsible for sabotaging recovery.

The study, which was published in JAMA Psychiatry, found that those with elevated activity in a region called the ventromedial prefrontal cortex (vmPFC) even while they were at rest were eight times more likely to drink again within 90 days than those whose vmPFC was calmer when they were feeling relaxed.

The findings are “a major contribution,” to understanding alcohol addiction, said Dr. Nora Volkow, director of the National Institute on Drug Abuse, in a co-written editorial that accompanied the research.

The authors, led by Rajita Sinha, professor of psychiatry at Yale University, studied the brain activity of 45 recovering alcoholics who were in a treatment program based on the 12 steps of Alcoholics Anonymous, during three different experiences — a stressful one, one that enticed them to drink, and a neutral, relaxing situation. The scientists compared their brain activity patterns to those of 30 social drinkers of similar age, intelligence and gender. The participants in the rehabilitation program were abstinent for four to eight weeks.

In order to generate the three experiences, the researchers asked all of the participants to describe recent stressful events, situations in which they ended up drinking, and circumstances that helped them to feel relaxed (such as sitting on a beach and listening to the waves). These were compiled into personalized two-minute videos that the team played back to the volunteers while they were brains were scanned using functional MRI. The scenarios induced the desired emotional states; heart rates rose during the stressful experiences and fell during the more relaxing ones.

But while the alcoholics appeared to be relaxed while picturing themselves on sunlit beaches, their brains — specifically the vmPFC — told a different story. “With relaxation, social drinkers relax their prefrontal cortex. It’s deactivation,” says Sinha, “For the alcoholic brain, what we found in this region was hyperactivity, as if it were stuck and primed and ready to go.” The alcoholics also showed elevated activity in an area linked with craving reward and pleasure even while they were relaxed.

Under stress, these regions also looked very different in the two groups. “[The stress response in] social drinkers goes up and responds as [it] needs to do when faced with a challenge: you want the system regulated to get ready for stress and to calm down afterwards. In the alcoholic brain, that [response] was flat or blunted,” Sinha says.

The discrepancy suggests that a more sensitive or active vmPFC could be making alcoholics vulnerable to drinking cues or to seeking out the satisfaction that comes from alcohol – a set-up for relapse. “The most important finding is the identification of a functional disruption in the brain that predicts who is most at risk for relapse,” Sinha says.

The vmPFC and the reward circuit are key nodes in the neural network that guides decision-making. These regions help to add value to experiences, allowing the brain to determine whether they will be helpful or harmful, punishing or pleasant.  “[Activity in these areas is] important in predicting what’s important and what’s not,” says Sinha, explaining that stimulating these circuits alerts other regions in the brain about how to respond once values are set. In the case of addictions, the heightened activity in these areas may bias the system to see the drugs or alcohol as more important than anything else.

“If it’s not working, and petered out like we’re showing [in the alcoholics], then other areas of brain like [those that control your] automatic response under stress are likely to override everything else,” she adds.  For alcoholics, not surprisingly, this automatic response would be to drink to satisfy cravings and respond to stress.

The findings may dovetail with the results from another study, published in the same issue of JAMA Psychiatry, that explored another key factor in alcoholic drinking: counteracting unpleasant moods.

Among more than 40,000 adults participating in the National Survey on Alcohol and Related Conditions, the researchers found that those who drank to lift their spirits tripled their risk of alcoholism, as well as prolonging the disorder.  The study estimated that nearly one-third of persistent alcoholism is linked to such self-medication, as well as 12% of new cases.

Both studies suggest potentially more sophisticated ways of addressing alcoholism by focusing on the stress and cues that can drive excessive drinking. In Sinha’s research, for example, the relapse rate overall was 71%— and it was even higher in those with over-activity in the vmPFC during relaxation. New approaches, such as mindfulness meditation, which could potentially calm the hyperactive alcoholic brain, might be more effective than programs that focus solely on changing behavior. Sinha is also studying a medication called Prazocin, which could affect the activity of the vmPFC. With better prediction of who is most likely to relapse, she says, could come better prevention strategies that are better tailored to what is driving alcoholics to drink again.

Read more: http://healthland.time.com/2013/05/02/bran-scan-can-predict-return-to-drinking/#ixzz2Wgf1vqWF

Lawmakers Want State Medical Board To Mine CURES Data

Tuesday, March 12, 2013

Lawmakers Want State Medical Board To Mine CURES Data

At a Joint Oversight Hearing of the state Legislature on Monday, lawmakers said that the Medical Board of California should mine data from a statewide prescription drug database to identify physicians who overprescribe medications, the Los Angeles Times reports (Girion/Glover, Los Angeles Times, 3/11).

About the Database

The Controlled Substance Utilization Review and Evaluation System — or CURES — tracks patients’ prescription drug history in an effort to curb illegal sales and misuse of prescription medication.

Funding for the system has decreased in recent years because of state budget cuts. The current budget is $400,000 annually.

A Times investigation conducted last year found the state’s oversight of physicians who overprescribe mediations to be lacking (California Healthline, 3/4).

Details of Hearing

At the hearing, several lawmakers said that the medical board should actively search CURES data for overprescribing patterns, instead of responding only to complaints about physicians’ prescribing habits.

Assembly member Richard Gordon (D-Menlo Park) said, “We ought to be mining that database rather than waiting for complaints,” adding, “I don’t think that the complaint-driven system has produced the appropriate results” (Los Angeles Times, 3/11).

Sharon Levin — president of the Medical Board of California — said that the board lacks the “statutory authority” to act without receiving a substantive complaint (Small, “KPCC News,” KPCC, 3/11). Later, Levin clarified that the medical board does have the authority to mine the data but lacks adequate staffing resources to do so (Los Angeles Times, 3/11).

The board has one month to respond in writing to questions posed by lawmakers at the hearing (Detrow, “State of Health,” KQED, 3/11).