Wisconsin Association of Alcohol and Other Drug Abuse

Implications for Treatment and Recovery of the ASAM Definition of Addiction Medicine

Michael M. Miller, MD, FASAM, FAPA

WAAODA 46th Annual Spring Conference

Plenary Session

Wednesday, May 23, 2012

Madison, WI

Michael M. Miller, MD, FASAM, [email protected]

Medical Director, Herrington Recovery Center (HRC) Rogers Memorial Hospital Oconomowoc, Wisconsin

Associate Clinical ProfessorUniversity of Wisconsin School of Medicine and Public Health

Associate Clinical ProfessorMedical College of Wisconsin, Dept of Psychiatry & Behavioral Health

Past President and Board ChairWisconsin and American Societies of Addiction Medicine

DirectorAmerican Board of Addiction Medicine

800-767-4411rogershospital.org

Rogers treats children, adolescents and adults with:•Anxiety disorders•Mood disorders•Eating disorders•Substance-use disorders

Learning Objectives

At the end of this presentation attendees will be able to:

1. Describe for patients and families how addiction is a disease of the brain and is “not just about drugs.”

2. Assess patients for pathological pursuits of reward and relief, utilizing the ASAM Definition of Addiction and the characteristic features described therein.

3. Address nicotine as an addictive drug deserving of inclusion in treatment plans for other drug addictions.

ASAM’s Mission

The American Society of Addiction Medicine’s mission is to:• Increase access to and improve the quality of addiction treatment;

• Educate physicians (including medical and osteopathic students), other health care providers and the public;

• Support research and prevention;

• Promote the appropriate role of the physician in the care of patients with addiction;

• Establish addiction medicine as a specialty recognized by professional organizations, governments, physicians, purchasers and consumers of health care services, and the general public.

Approved by ASAM Board, 7-2006; http://198.65.155.172/CMS/images/PDF/General/Strategic%20Plan.pdf

Addiction Medicine:

The specialty of medicine devoted to diagnosis, treatment, prevention, education, epidemiology, research, and public policy advocacy regarding addiction and other substance-related health conditions

How to Identify a Physician Recognized for Expertise in the Diagnosis and Treatment of Addiction and Substance-related Health Conditions (ASAM Public Policy Statement)

www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html

www.asam.org/HowToIdentifyaPhysicianRecognizedforExpertness.html

• Completion of a residency/fellowship in Addiction Medicine or Addiction Psychiatry

• Certification in Addiction Medicine by the American Society of Addiction Medicine (ASAM)

• Subspecialty certification in Addiction Psychiatry by the American Board of Psychiatry and Neurology (ABPN)

• A Certificate of Added Qualification in Addiction Medicine conferred by the American Osteopathic Association (AOA)

• Board Certification in Addiction Medicine by the American Board of Addiction Medicine (ABAM)

Addiction is not…

• Just a social problem• Just a criminal problem• Just a moral problem

• Frequent intoxication, heavy use, having fun• High frequency / high quantity use

• Physical Dependence

Addiction is…

• A BRAIN DISEASE

• A primary, relapsing and remitting CHRONIC DISEASE….

• A PEDIATRIC DISEASE….

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Addiction is a Developmental Disease

How is it that DRUGS are different from broccoli?

• It’s because of what ‘drugs’ do to the BRAIN• Drugs enter the body via various routes– Oral, Intravenous, Intramuscular, Intranasal, transdermal,

transbuccal, or transalveolar

• Drugs that affect mood/thought/behavior cross the ‘blood brain barrier’

• Drugs act on nerve cells by binding to specialized portions of the outer membrane of nerve cells

Addiction ‘Resides’ in the Orbitofrontal Cortex (OFC) and in connections between OFC et al.

• Addiction is use despite adverse consequences, returning to use after periods of abstinence even with previous life catastrophes, inability to control use, cognitive preoccupation, conscious and unconscious craving

• It involves memory, judgment, ‘executive functions’ of planning and deciding to defer gratification

• All these are Frontal Lobe functions



• The site of action for reward/drug-induced euphoria is the nucleus accumbens (an oversimplification)

• The site of action for addiction is interplay between the frontal lobes and the Nuc Acc, and among the Nuc Acc, the hippocampus (memory), and the amygdala (motivation)– Judgment / Evaluation

– Planning

– Drive (drug hunger/craving; drug seeking/use)

– Recalling past experiences

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Circuits Involved in Drug Abuse and Addiction

Addiction ‘resides’ somewhat in the Orbitofrontal Cortex (OFC) and in other areas with connections to Reward Circuitry

• The site of acute action for euphoriants is the nucleus accumbens (an oversimplification)

• The site of action for the chronic, recurrent, relapsing exposure to euphoriants--as is see in addiction—is the interplay among the Nuc Acc, the hippocampus (memory; recalling past experiences), the amygdala (motivation, drive, drug hunger/craving; drug seeking/use), and the frontal lobes (judgment/evaluation, planning, delay of gratification, inhibition of urges/impulses)

What is Addiction? American Society of Addiction Medicine • April 2011

Definition of Addiction:“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

• Question: Why is ASAM, as a medical organization, talking about “spirituality”?

• Answer: Because the members of the DDTAG, and of the BOD, recognize the multidimensional aspect of both the disease and of recovery

• Values matter• Violating your own values,

then re-establishing your values, matters.• Connectedness matters.• Meaning in life matters.• Recovery is many things,

including a search for meaning.

Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.

Definition of AddictionAmerican Society of Addiction Medicine • April 2011

“Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

Downward Spiral / Progression

Addiction(constriction –of affects, behaviors, social network)

Atrophy

• Of social network– People…

• Of activities / interests – Places, Things

• Of emotions– Flatness, less expressive, dysthymic / alexithymic

• Of rewards– Salience

Copyright (c)2011, Covington, Griffin, & Dauer

Downward Spiral of Addiction andUpward Spiral of Recovery

Addiction(constriction –of affects, behaviors, social network)

Recovery(expansion—of feelings, rewards,activities, social connections)

How to come out of the depths?How to RECOVER?

• Re-people-ization– AA

– Sponsor

– Church

– Social clubs

– Activities with others

– Family

• Professional Treatment (group therapy, meet others)• Re-Connectedness

ASAM Public Policy Statement: Definition of Addiction (Long Version)

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors.

ASAM Public Policy Statement: Definition of Addiction (Long Version)

Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.

The neurobiology of addiction encompasses more than the neurochemistry of reward.1

The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation and memory are fundamental in the manifestations of altered impulse control, [and] altered judgment….

…and the dysfunctional pursuit of rewards (which is often experienced by the affected person as a desire to “be normal”) seen in addiction--despite cumulative adverse consequences experienced from engagement in substance use and other addictive behaviors.

Footnote 1: The neurobiology of reward has been well understood for decades, whereas the neurobiology of addiction is still being explored. Most clinicians have learned of reward pathways including projections from the ventral tegmental area (VTA) of the brain, through the median forebrain bundle (MFB), and terminating in the nucleus accumbens (Nuc Acc), in which dopamine neurons are prominent. Current neuroscience recognizes that the neurocircuitry of reward also involves a rich bi-directional circuitry connecting the nucleus accumbens and the basal forebrain.

Footnote 1 (continued): It is the reward circuitry where reward is registered, and where the most fundamental rewards such as food, hydration, sex, and nurturing exert a strong and life-sustaining influence. Alcohol, nicotine, other drugs and pathological gambling behaviors exert their initial effects by acting on the same reward circuitry that appears in the brain to make food and sex, for example, profoundly reinforcing. Other effects, such as intoxication and emotional euphoria from rewards, derive from activation of the reward circuitry.

Footnote 1 (continued): While intoxication and withdrawal are well understood through the study of reward circuitry, understanding of addiction requires understanding of a broader network of neural connections involving forebrain as well as midbrain structures. Selection of certain rewards, preoccupation with certain rewards, response to triggers to pursue certain rewards, and motivational drives to use alcohol and other drugs and/or pathologically seek other rewards, involve multiple brain regions outside of reward neurocircuitry itself.

Genetic factors account for about half of the likelihood that an individual will develop addiction.

Environmental factors interact with the person’s biology and affect the extent to which genetic factors exert their influence. Resiliencies the individual acquires (through parenting or later life experiences) can affect the extent to which genetic predispositions lead to the behavioral and other manifestations of addiction. Culture also plays a role in how addiction becomes actualized in persons with biological vulnerabilities to the development of addiction.

Addiction is characterized by2:

• Inability to consistently Abstain;

• Impairment in Behavioral control;

• Craving; or increased “hunger” for drugs or rewarding experiences;

• Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and

• A dysfunctional Emotional response.

Footnote 2: These five features are not intended to be used as “diagnostic criteria” for determining if addiction is present or not. Although these characteristic features are widely present in most cases of addiction, regardless of the pharmacology of the substance use seen in addiction or the reward that is pathologically pursued, each feature may not be equally prominent in every case. The diagnosis of addiction requires a comprehensive biological, psychological, social and spiritual assessment.

Naqvi NH, Bechara ATrends in Neurosciences, 32:56-67, 2008

“…Studies using animal models [which] have emphasized the role of subcortical systems such as the amygdala, nucleus accumbens and the mesolimbic dopamine system…have tended to focused on externally observable aspects of addiction (emphasis added)”

The power of external cues to trigger craving and drug use,

…as well as to increase the frequency of engagement in other potentially addictive behaviors, is also a characteristic of addiction, with the hippocampus being important in memory of previous euphoric or dysphoric experiences, and with the amygdala being important in having motivation concentrate on selecting behaviors associated with these past experiences.

Although some believe that the difference between those who have addiction, and those who do not, is the quantity or frequency of alcohol/drug use, engagement in addictive behaviors (such as gambling or spending) 3, or exposure to other external rewards (such as food or sex)…,

…a characteristic aspect of addiction is the qualitative way in which the individual responds to such exposures, stressors and environmental cues. A particularly pathological aspect of the way that persons with addiction pursue substance use or external rewards is that preoccupation with, obsession with and/or pursuit of rewards (e.g., alcohol, nicotine and other drug use) persist despite the accumulation of adverse consequences. These manifestations can occur compulsively or impulsively, as a reflection of impaired control.

Footnote 3: In this document, the term "addictive behaviors" refers to behaviors that are commonly rewarding and are a feature in many cases of addiction. Exposure to these behaviors, just as occurs with exposure to rewarding drugs, is facilitative of the addiction process rather than causative of addiction. The state of brain anatomy and physiology is the underlying variable that is more directly causative of addiction.

Footnote 3: Thus, in this document, the term “addictive behaviors” does not refer to dysfunctional or socially disapproved behaviors, which can appear in many cases of addiction. Behaviors, such as dishonesty, violation of one’s values or the values of others, criminal acts etc., can be a component of addiction; these are best viewed as complications that result from rather than contribute to addiction.

In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications.

Addiction is more than a behavioral disorder.

Features of addiction include aspects of a person’s behaviors, cognitions, emotions, and interactions with others, including a person’s ability to relate to members of their family, to members of their community, to their own psychological state, and to things that transcend their daily experience.

Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:

• Excessive use and/or engagement in addictive behaviors, at higher frequencies and/or quantities than the person intended, often associated with a persistent desire for and unsuccessful attempts at behavioral control;

• Excessive time lost in substance use or recovering from the effects of substance use and/or engagement in addictive behaviors, with significant adverse impact on social and occupational functioning (e.g. the development of interpersonal relationship problems or the neglect of responsibilities at home, school or work);

Behavioral manifestations and complications of addiction, primarily due to impaired control, can include:

• Continued use and/or engagement in addictive behaviors, despite the presence of persistent or recurrent physical or psychological problems which may have been caused or exacerbated by substance use and/or related addictive behaviors;

• A narrowing of the behavioral repertoire focusing on rewards that are part of addiction; and

• An apparent lack of ability and/or readiness to take consistent, ameliorative action despite recognition of problems.

Griffith Edwards (1976)

“…as dependence advances…the individual gives priority to maintaining his alcohol intake; indeed the failure of unpleasant consequences to deter may be a clinical indicator of the degree of dependence.”

Cognitive changes in addiction can include:

• Preoccupation with substance use;

• Altered evaluations of the relative benefits and detriments associated with drugs or rewarding behaviors; and

• The inaccurate belief that problems experienced in one’s life are attributable to other causes rather than being a predictable consequence of addiction.

Emotional changes in addiction can include:

• Increased anxiety, dysphoria and emotional pain;

• Increased sensitivity to stressors associated with the recruitment of brain stress systems, such that “things seem more stressful” as a result; and

• Difficulty in identifying feelings, distinguishing between feelings and the bodily sensations of emotional arousal, and describing feelings to other people (sometimes referred to as alexithymia).

The emotional aspects of addiction are quite complex.

• Some persons use alcohol or other drugs or pathologically pursue other rewards because they are seeking “positive reinforcement” or the creation of a positive emotional state (“euphoria”).

• Others pursue substance use or other rewards because they have experienced relief from negative emotional states (“dysphoria”), which constitutes “negative reinforcement.“

• Beyond the initial experiences of reward and relief, there is a dysfunctional emotional state present in most cases of addiction that is associated with the persistence of engagement with addictive behaviors.

The state of addiction is not the same as the state of intoxication.

When anyone experiences mild intoxication through the use of alcohol or other drugs, or when one engages non-pathologically in potentially addictive behaviors such as gambling or eating, one may experience a “high”, felt as a “positive” emotional state associated with increased dopamine and opioid peptide activity in reward circuits. After such an experience, there is a neurochemical rebound, in which the reward function does not simply revert to baseline, but often drops below the original levels. This is usually not consciously perceptible by the individual and is not necessarily associated with functional impairments.

Over time, repeated experiences with substance use or addictive behaviors are not associated with ever increasing reward circuit activity and are not as subjectively rewarding. Once a person experiences withdrawal from drug use or comparable behaviors, there is an anxious, agitated, dysphoric and labile emotional experience, related to suboptimal reward and the recruitment of brain and hormonal stress systems, which is associated with withdrawal from virtually all pharmacological classes of addictive drugs.

While tolerance develops to the “high,” tolerance does not develop to the emotional “low” associated with the cycle of intoxication and withdrawal. Thus, in addiction, persons repeatedly attempt to create a “high”--but what they mostly experience is a deeper and deeper “low.” While anyone may “want” to get “high”, those with addiction feel a “need” to use the addictive substance or engage in the addictive behavior in order to try to resolve their dysphoric emotional state or their physiological symptoms of withdrawal.

Persons with addiction compulsively use even though it may not make them feel good, in some cases long after the pursuit of “rewards” is not actually pleasurable.5 Although people from any culture may choose to “get high” from one or another activity, it is important to appreciate that addiction is not solely a function of choice. Simply put, addiction is not a desired condition.

Edgar Degas

L 'Absinthe (The Absinthe Drinker)1875-76

Musée d'OrsayParis, France

Footnote 5: Pathologically pursuing reward (mentioned in the Short Version of this definition) thus has multiple components. It is not necessarily the amount of exposure to the reward (e.g., the dosage of a drug) or the frequency or duration of the exposure that is pathological.

Footnote 5 (continued): In addiction, pursuit of rewards persists, despite life problems that accumulate due to addictive behaviors, even when engagement in the behaviors ceases to be pleasurable. Similarly, in earlier stages of addiction, or even before the outward manifestations of addiction have become apparent, substance use or engagement in addictive behaviors can be an attempt to pursue relief from dysphoria; while in later stages of the disease, engagement in addictive behaviors can persist even though the behavior no longer provides relief.

As addiction is a chronic disease, periods of relapse, which may interrupt spans of remission, are a common feature of addiction. It is also important to recognize that return to drug use or pathological pursuit of rewards is not inevitable.

Clinical interventions can be quite effective in altering the course of addiction. Close monitoring of the behaviors of the individual and contingency management, sometimes including behavioral consequences for relapse behaviors, can contribute to positive clinical outcomes. Engagement in health promotion activities which promote personal responsibility and accountability, connection with others, and personal growth also contribute to recovery. It is important to recognize that addiction can cause disability or premature death, especially when left untreated or treated inadequately.

As is the case with other chronic diseases, the condition must be monitored and managed over time to: •Decrease the frequency and intensity of relapses;

•Sustain periods of remission; and

•Optimize the person’s level of functioning during periods of remission.

• In some cases of addiction, medication management can improve treatment outcomes.

• In most cases of addiction, the integration of psychosocial rehabilitation and ongoing care with evidence-based pharmacological therapy provides the best results.

• Chronic disease management is important for minimization of episodes of relapse and their impact.

• Treatment of addiction saves lives †

TreatAddiction

SaveLives

© ASAM

BEHAVIORAL CHANGES

• Eliminate alcohol and other drug use behaviors• Eliminate other problematic

behaviors• Expand repertoire of healthy

behaviors• Develop alternative behaviors

BIOLOGICAL CHANGES

• Resolve acute alcohol and other drug withdrawal symptoms• Physically stabilize the organism• Develop sense of personal

responsibility for wellness• Initiate health promotion

activities (e.g., diet, exercise, safe sex, sober sex)

Targeted Therapeutic Changes in Addiction Treatment

COGNITIVE CHANGES

• Increase awareness of illness• Increase awareness of negative

consequences of use• Increase awareness of addictive

disease in self• Decrease denial

AFFECTIVE CHANGES

• Increase emotional awareness of negative consequences of use• Increase ability to tolerate

feelings without defenses• Manage anxiety and depression• Manage shame and guilt


SOCIAL CHANGES

• Increase personal responsibility in all areas of life• Increase reliability and

trustworthiness• Become resocialized:

reestablished sober social network• Increase social coping skills:

with spouse/partner, with colleagues, with neighbors, with strangers

SPIRITUAL CHANGES

• Increase self-love/esteem; decrease self-loathing• Reestablish personal values• Enhance connectedness• Increase appreciation of

transcendence


Miller, Michael M. Principles of Addiction Medicine, 1994; published by American Society of Addiction Medicine, Chevy Chase, MD

Traditional Targets of “Substance Abuse Treatment”

• Alcohol abuse and dependence.• Sedative abuse and dependence.• Cocaine abuse and dependence.• Stimulant abuse and dependence.• Opioid abuse and dependence.• Cannabinoid abuse and dependence.• Hallucinogen abuse and dependence.• Dissociative Drug abuse and dependence.• Inhalant abuse and dependence.

Topics Often Not Addressed in Traditional “Substance Abuse Treatment”

• Codependency

• Nicotine dependence.

• Pathological gambling.

• Sexual compulsivity.

• Compulsive overeating.

• Compulsive shopping/spending/debting.

• Compulsive Internet/computer game/video game playing.

Nicotine Addiction

• Clearly, nicotine is the rewarding/reinforcing substance in tobacco

• ASAM’s tag line is “Treat Addiction Save Lives”• If any addiction professional is interested in saving lives,

tobacco/nicotine must be targetedDEATHS per year:• Tobacco = 440,000• Alcohol = 110,000• Opioid pills = 38,000• Other drugs = less than 20,000 (if you exclude HIV/HCV)

Nicotine

• Acts on acetyl choline receptors, the nicotinic subtype of the A Ch receptor.

• Actions• Harms– Heat

– Carbon monoxide

– Solids in smoke (nitrosamines and other carcinogens)

• Second Hand Smoke• Third Hand Smoke

Addiction is characterized by2:

• Inability to consistently Abstain;

• Impairment in Behavioral control;

• Craving; or increased “hunger” for drugs or rewarding experiences;

• Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and

• A dysfunctional Emotional response.

How is tobacco/nicotine addiction treated?

• Education (groups offered by American Lung Assn, AHA)• Behavioral therapy (behavioral analysis of smoking

situations/circumstances; addressing high-risk situations; changing the environment to reduce cue exposure)

• Pharmacotherapy– NRT (“gum”, lozenges, patches, inhalers, nasal sprays)

– Bupropion (Zyban®) or other antidepressants

– Varenicline (Chantix®) – partial agonist

– Clonidine

How has tobacco/nicotine addiction not been treated?• Intensive Outpatient– Multiple sessions per week– Combination of psychoeducational and psychotherapeutic groups– Group THERAPY

• Family therapy• Continuing care groups (relapse prevention)• Insistence on abstinence• Monitoring of abstinence (urine cotinine levels)• 12-step approaches (they exist, but not widespread: Nicotine

Anonymous is ‘the other NA’; Smokers Anonymous is ‘the other SA’)

What if the ASAM Definition guided treatment planning?

• Comprehensive assessment– Age of first use, age of first regular use, problems from use, loss

of control, preoccupation, ABCDE

• All pathological sources of reward/relief are relevant– Could be a problem now, or could become a problem later

• Insist on abstinence– Use of any substance that activates reward circuitry is dangerous

in a person with this disease

Considering the alternative: not treat tobacco/nicotine addiction concurrently?

• Is it an addiction?• Is it harmful (causing dysfunction, illness, death)?• If a patient were to say “I want help for heroin and

cocaine, but I want to be able to continue to smoke tobacco -- I just can’t do everything at once” – how would you react?

• Does continuing to “tweak” the reward circuitry with a powerful agonist affect relapse to a person’s “drug of choice”?

• Physician Health Program data.

Gambling Addiction (DSM-IV approach)

The following are the diagnostic criteria from the DSM-IV for 312.31 (Pathological Gambling):

A. Persistent and recurrent maladaptive gambling behavior as indicated by at least five of the following:1. is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) 2. needs to gamble with increasing amounts of money in order to achieve the desired excitement 3. has repeated unsuccessful efforts to control, cut back, or stop gambling 4. is restless or irritable when attempting to cut down or stop gambling 5. gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression).

Gambling Addiction (DSM-IV approach)

6. after losing money gambling, often returns another day in order to get even (“chasing” one’s losses)

7. lies to family members, therapist, or others to conceal the extent of involvement with gambling

8. has committed illegal acts, such as forgery, fraud, theft, or embezzlement, in order to finance gambling

9. has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling

10. relies on others to provide money to relieve a desperate financial situation caused by gambling

B. The gambling behavior is not better accounted for by a Manic Episode.

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.

Epidemiology

• 1 – 2 % of adults

• 2 – 4 % of adolescents

• Most severe cases associated with the rapidity of reinforcement (IV route of drug administration is more addictive than oral route; video poker is more addictive than racetracks; OTB parlors are more addictive than in vivo)

• Availability drives up exposure; exposure leads to increased rates of addiction

Physiology of Gambling Addiction

• Causes release of dopamine in nucleus accumbens

• Leads to same changes in neurophysiology as do exposure to cocaine and other stimulants

• Neuroimaging studies.

DSM-V Gambling Disorder

The work group has proposed that this diagnosis be reclassified from Impulse-Control Disorders Not Elsewhere Classified to Substance-Related Disorders which will be renamed Addiction and Related Disorders

A. Persistent and recurrent problematic gambling behavior as indicated by four (or more) of the following in a 12-month period:1. needs to gamble with increasing amounts of money in order to achieve the desired excitement2. is restless or irritable when attempting to cut down or stop gambling 3. has repeated unsuccessful efforts to control, cut back, or stop gambling4. is often preoccupied with gambling (e.g., persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)

DSM-V Gambling Disorder

5. gambles often when feeling distressed (e.g., helpless, guilty, anxious, depressed)

6. after losing money gambling, often returns another day to get even (“chasing” one’s losses)

7. lies to conceal the extent of involvement with gambling

8. has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling

9. relies on others to provide money to relieve desperate financial situations caused by gambling

DSM 5 Gambling Disorder

B. The gambling behavior is not better accounted for by a Manic Episode.

Course Specifiers.

- Episodic- Chronic- In Remission

Addiction: Associated with Internet/Video Games

• Didn’t “make the cut” with DSM-V, but it came close!• Reinforcement can be rapid and repeated– Inability to consistently Abstain;

– Impairment in Behavioral control;

– Craving; or increased “hunger” for drugs or rewarding experiences;

– Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and

– A dysfunctional Emotional response.

Internet Use Disorder (DSM-V)

This condition is being recommended for further study in Section III, which is the section of the DSM-V text in which conditions that require further research will be included.

A. Preoccupation with Internet gaming

B. Withdrawal symptoms when internet is taken away

C. Tolerance: the need to spend increasing amounts of time engaged in Internet gaming

D. Unsuccessful attempts to control Internet gaming use

Internet Use Disorder (DSM-V)

E. Continued excessive Internet use despite knowledge of negative psychosocial problems

F. Loss of interests, previous hobbies, entertainment as a result of, and with the exception of Internet gaming use

G. Use of the Internet gaming to escape or relieve a dysphoric mood

H. Has deceived family members, therapists, or others regarding the amount of Internet gaming

I. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of Internet gaming use

Addiction: Associated with Sex

This condition is being recommended for further study in Section III, which is the section of the DSM-5 text in which conditions that require further research will be included.

Hypersexual Disorder

A. Over a period of at least 6 months, recurrent and intense sexual fantasies, sexual urges, and sexual behavior in association with four or more of the following five criteria:(1) excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior(2) repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability)(3) repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events (4) repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior(5) repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others



Hypersexual Disorder B. There is clinically significant distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior. C. These sexual fantasies, urges, and behavior are not due to direct physiological effects of exogenous substances (e.g., drugs of abuse or medications), a co-occurring general medical condition or to Manic Episodes. D. The individual is at least 18 years of age.

Specify if:–In a Controlled Environment–In Remission (No Distress, Impairment, or Recurring Behavior for Five Years and in an Uncontrolled Environment)Environment



Hypersexual Disorder

Specify if: –Masturbation–Pornography–Sexual Behavior With Consenting Adults–Cybersex–Telephone Sex–Adult Entertainment Venues/Clubs–Other:

Addiction Associated with Sex is characterized by:

• Inability to consistently Abstain; • Impairment in Behavioral control; • Craving; or increased “hunger” for drugs or rewarding

experiences; • Diminished recognition of significant problems with

one’s behaviors and interpersonal relationships; and • A dysfunctional Emotional response. – Keep doing it even when it doesn’t produce positive emotion

– Subcortical drive to produce experience of “reward”

Addiction: Associated with Pornography

Addiction: Associated with Eating

Binge Eating Disorder (DSM-V)A. Recurrent episodes of binge eating. An episode of binge eating is characterized by

both of the following:1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food

that is definitely larger than most people would eat in a similar period of time under similar circumstances

2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating)

B. The binge-eating episodes are associated with 3 (or more) of the following:1. Eating much more rapidly than normal. 2. Eating until feeling uncomfortably full 3. Eating large amounts of food when not feeling physically hungry 4. Eating alone because of feeling embarrassed by how much one is eating. 5. Feeling disgusted with oneself, depressed, or very guilty after overeating.

Addiction: Associated with Eating

Binge Eating Disorder (DSM-V)

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least once a week for 3 months.

E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior and does not occur exclusively during the course Bulimia Nervosa or Anorexia Nervosa.

Not called “Compulsive Overeating” by DSM-V committee.

Not called “Eating Addiction.”

Nothing in DSM-V re: addictive food restriction or addictive exercise

“Switching Addictions”?…..or is it just one illness?

• Alcoholism → Sedativism

• Alcoholism → cocaine, opioids, cannabinoids

• Cocaine → gambling, sexual compulsivity

• Obesity → Alcoholism

• Alcoholism → Obesity

• Bariatric Surgery → Alcoholism

• Nicotine → all other drugs

Implications of the ASAM Definition for Treatment

• A significant feature of the ASAM approach is to outline that addiction is best understood as a unitary condition: addiction is addiction.

• Addiction can involve drinking, smoking, gambling, or even purging, but the ASAM definition does not describe alcohol addiction, nicotine addiction, gambling addiction, or purging addiction as separate entities. ASAM, through the work of its Descriptive and Diagnostic Terminology Action Group, has defined “Addiction” and would discourage focus on “the Addictions.”


• Whereas the DSM and ICD systems may continue to have separate diagnostic codes based on specific substances and behaviors, ASAM is suggesting the unitary approach, focusing on the internal brain processes in addiction rather than putting focus on various external sources of reward or relief. The unitary approach can also ensure that assessment and treatment are much more comprehensive, in which abstinence from all psychoactive substances would be recommended and monitoring of all potential addictive behaviors would be needed on an ongoing basis.


• It is essential to ensure that health care providers, patients and their families understand that the individual with this disease is vulnerable to loss of control with engagement with other addictive substances and behaviors than the ones that led them to seek help.


• While research may be done to carefully delineate inclusion and exclusion criteria for things such as “Internet addiction” or “sex addiction”, the ASAM approach would say simply that an individual has “addiction,” though it could specify the condition with terms such as “addiction associated with alcohol” or “addiction associated with gambling” or “addiction associated with hallucinogens” or “addiction associated with spending and debting.”

The Physiology of Addiction

Certain substances have the ability to interact with the brain’s Reward Circuitry and are thus euphoriants; they are reinforcing, and, in lab animals, self-reinforcing. They act first by being external ligands for neuro-transmitter receptors, or by causing release of (or otherwise altering levels of) neuro-transmitters.

They hijack the reward system, and the individual compulsively pursues these rewards instead of natural rewards.


Once the Reward Circuitry is turned on, there are changes in related brain areas or neuronal circuits, and these result in the characteristic manifestations of addiction [altered memory of past intoxication experiences, altered cue response, changes in motivation so that ‘the drug’ (can be a substance, or a pathologically rewarding activity) becomes ‘the salient reinforcer,’ replacing other healthy reward]. All this contributes to preoccupation and loss of control.


• Changes in frontal lobe function (executive functioning; the inhibition of impulses to use) are key: the brain fails in efforts to inhibit the drive to obtain/use the drug to create ‘the high’.

• Impairment in control and preoccupation are the key behavioral/cognitive characteristics of addiction, and have an anatomical/physiological substrate in the brain.

• Relapse is intrinsic to virtually all chronic diseases; the animal model of relapse is “reinstatement” of drug use or drug preference.

PFCPFC

ACGACG

OFCOFCSCCSCC

HippHipp

NAccNAccVPVP

Amyg

Amyg

REWARDREWARD

CONTROL INHIBITORY

CONTROL

CONTROL INHIBITORY

CONTROL

MOTIVATION/DRIVE

MOTIVATION/DRIVE

MEMORY/LEARNING MEMORY/

LEARNING

Circuits Involved in Drug Abuse and Addiction

Addiction professionals and persons in recovery know the hope that is found in recovery. Recovery is available even to persons who may not at first be able to perceive this hope, especially when the focus is on linking the health consequences to the disease of addiction.

As in other health conditions, self-management, with mutual support, is very important in recovery from addiction.

Peer support such as that found in various “self-help” activities is beneficial in optimizing health status and functional outcomes in recovery. ‡

Recovery from addiction is best achieved through a combination of self-management, mutual support, and professional care provided by trained and certified professionals.

NIDA Principles of Drug Addiction Treatment (1999, rev 2009)

1. Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased.

2. No single treatment is appropriate for everyone.

NIH Publication No. 09–4180

The Herrington Recovery Center

Thank you!

The Herrington Recovery Centerat Rogers Memorial Hospital

For more information, call 800-767-4411or visitrogershospital.org

Michael M. Miller, MD, FASAM, [email protected]

Health & Medicine

Wisconsin Association of Alcohol and Other Drug Abuse