Dr. Lynn Hankes presented at the 2013 Farley Alumni Meeting.

1. ARE ALCOHOLISM & DRUGARE ALCOHOLISM & DRUG
ADDICTION REALLYADDICTION REALLY
DISEASES, AND IF SO,DISEASES, AND IF SO,
SO WHAT ?SO WHAT ?
THE FARLEY CENTERTHE FARLEY CENTER
04/13/1304/13/13
WILLIAMSBURG, VAWILLIAMSBURG, VA

2. LYNNLYNN HANKESHANKES, MD, FASAM, MD, FASAM
Clinical Professor EmeritusClinical Professor EmeritusClinical Professor EmeritusClinical Professor Emeritus
Department of PsychiatryDepartment of Psychiatry
and Behavioral Scienceand Behavioral Science
University of WashingtonUniversity of Washington
School of MedicineSchool of Medicine
SeattleSeattle

3. ADDICTIONADDICTION
ALCOHOLISMALCOHOLISM
& ANY& ANY OTHEROTHER
DRUG DEPENDENCYDRUG DEPENDENCY
==
CHEMICAL DEPENDENCYCHEMICAL DEPENDENCY

4. CHEMICAL IS ADDICTIVE IFCHEMICAL IS ADDICTIVE IF
1. MIND ALTERING1. MIND ALTERING--MOOD CHANGINGMOOD CHANGING1. MIND ALTERING1. MIND ALTERING--MOOD CHANGINGMOOD CHANGING
2. REINFORCING2. REINFORCING
3. EUPHORIGENIC3. EUPHORIGENIC

5. NOT ADDICTIVENOT ADDICTIVE
ANTIDEPRESANTSANTIDEPRESANTS
LITHIUMLITHIUM
ANTIANTI--PSYCHOTICSPSYCHOTICS

6. CHEMICAL CLASSESCHEMICAL CLASSES
OPIOIDSOPIOIDS
SEDATIVESEDATIVE--HYPNOTICSHYPNOTICS
STIMULANTSSTIMULANTS
PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS
CANNABINOIDSCANNABINOIDS
INHALANTSINHALANTS

7. ADDICTIVE POTENTIALADDICTIVE POTENTIAL
COCAINE/METHAMPHETAMINECOCAINE/METHAMPHETAMINE
SYNTHETIC OPIOIDS (FENTANYL)SYNTHETIC OPIOIDS (FENTANYL)
HEROINHEROINHEROINHEROIN
MINOR OPIOIDSMINOR OPIOIDS
NICOTINENICOTINE
ALCOHOLALCOHOL

8. ADDICTIVE POTENTIALADDICTIVE POTENTIAL
OTHER SEDATIVESOTHER SEDATIVES
OTHER STIMULANTSOTHER STIMULANTS
PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS
CANNABINOIDSCANNABINOIDS
CAFFEINECAFFEINE

9. U.S. MORTALITYU.S. MORTALITY
ILLEGAL DRUGSILLEGAL DRUGS
ALCOHOLALCOHOL
10 PER DAY10 PER DAY
400 PER DAY400 PER DAYALCOHOLALCOHOL
??
NICOTINENICOTINE
400 PER DAY400 PER DAY
1000 PER DAY1000 PER DAY

10. DEPENDENCYDEPENDENCY
Loss OfLoss Of CControlontrol
CCompulsive Useompulsive UseCCompulsive Useompulsive Use
Continued Use DespiteContinued Use Despite
AdverseAdverse CConsequencesonsequences

11. ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
IGNORANTIGNORANT
STUPIDSTUPID
CRAZYCRAZY
IMMORALIMMORAL
WEAKWEAK
SICKSICK

12. ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
IGNORANTIGNORANTIGNORANTIGNORANT
STUPIDSTUPID
EDUCATIONEDUCATION

13. ACTIVITYACTIVITY------PROBLEMSPROBLEMS
CRAZYCRAZY PSYCHOPSYCHO--
TXTX

14. ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
IMMORALIMMORAL CHURCH/JAILCHURCH/JAIL

15. ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
WEAKWEAK
WILLEDWILLED
“JUST SAY NO“JUST SAY NO””

16. ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
SICKSICK TREATMENTTREATMENT

17. DISEASEDISEASE
A DYSFUNCTIONALA DYSFUNCTIONALA DYSFUNCTIONALA DYSFUNCTIONAL
STATE WITHSTATE WITH
CHARACTERISTICCHARACTERISTIC
FORMFORM

18. CHARACTERISTIC FORMCHARACTERISTIC FORM
CAUSECAUSE
SPECIFIC DEFECTSPECIFIC DEFECT
SXSX--SIGNSSIGNS--LAB TESTSLAB TESTSSXSX--SIGNSSIGNS--LAB TESTSLAB TESTS
PREDICTABLE COURSEPREDICTABLE COURSE
UNIFORM TREATMENTUNIFORM TREATMENT
SIMILAR RESPONSESIMILAR RESPONSE

19. COMPARE DISEASESCOMPARE DISEASES
DIABETESDIABETES
AIDSAIDSAIDSAIDS
CHEMICALCHEMICAL
DEPENDENCYDEPENDENCY

20. DIABETESDIABETES
CAUSECAUSE
DEFECTDEFECT
UNKNOWNUNKNOWN
Insulin ImbalanceInsulin Imbalance
YESYESSXSX--SIGNSSIGNS--LABLAB
COURSECOURSE
SAME TXSAME TX
RESPONSERESPONSE
YESYES
YESYES
DietDiet--PillsPills--InsulinInsulin
YESYES

21. AIDSAIDS
CAUSECAUSE
DEFECTDEFECT
HIV +/HIV +/-- CoCo--FF
T 4 CELLT 4 CELL
SXSX--SIGNSSIGNS--LABLAB
COURSECOURSE
SAME TXSAME TX
RESPONSERESPONSE
YESYES
YESYES
UNKNOWNUNKNOWN
N/AN/A

22. CHEMICAL DEPENDENCYCHEMICAL DEPENDENCY
CAUSECAUSE
DEFECTDEFECT
UNKNOWNUNKNOWN
CHEM/PSY IMBLNCECHEM/PSY IMBLNCE
YESYESSXSX--SIGNSSIGNS--LABLAB
COURSECOURSE
SAME TXSAME TX
RESPONSERESPONSE
YESYES
YESYES
AAAA--OUT PTOUT PT--IN PTIN PT
YESYES

23. “MEDICALIZE”“MEDICALIZE”-- IT’S AIT’S A
DISEASE BECAUSE:DISEASE BECAUSE:
BEING SICK IS LESS SHAMEFUL THANBEING SICK IS LESS SHAMEFUL THAN
WILLFUL MISCONDUCTWILLFUL MISCONDUCTWILLFUL MISCONDUCTWILLFUL MISCONDUCT
THEN INSURANCE WILL PAY FOR TXTHEN INSURANCE WILL PAY FOR TX
HAVING AN ILLNESS ABSOLVES ONEHAVING AN ILLNESS ABSOLVES ONE
FROM SOCIAL RESPONSIBILITYFROM SOCIAL RESPONSIBILITY

24. DISEASE CHARACTERISTICSDISEASE CHARACTERISTICS
CHRONICCHRONIC
PRIMARYPRIMARYPRIMARYPRIMARY
PREDICTABLEPREDICTABLE
“CATCHING”“CATCHING”

25. CHRONICITYCHRONICITY
PERMANENTPERMANENT
NOT ALCOHOLNOT ALCOHOL--WASWAS--MM
BUT ALCOHOLBUT ALCOHOL--------ISIS--MM
PRONE TO RELAPSEPRONE TO RELAPSE
DIABETESDIABETES
CORONARY INSUFFICIENCYCORONARY INSUFFICIENCY
ALCOHOLISMALCOHOLISM

26. PRIMARYPRIMARY
PRIMARY: Stands alone independentlyPRIMARY: Stands alone independently
SECONDARY: To underlying primary ds.SECONDARY: To underlying primary ds.
NEUROSISNEUROSISNEUROSISNEUROSIS
PSYCHOSISPSYCHOSIS

27. PREDICTABLEPREDICTABLE
Often progressive in 4 Stages:Often progressive in 4 Stages:
EARLYEARLY---->>EARLYEARLY---->>
MIDDLEMIDDLE---->>
LATELATE---->>
TOO LATE +TOO LATE +

28. “CATCHING”“CATCHING”
THE ________ IS “CATCHING”THE ________ IS “CATCHING”
THETHE INSANITYINSANITY IS “CATCHING!”IS “CATCHING!”THETHE INSANITYINSANITY IS “CATCHING!”IS “CATCHING!”
The stress of living with an alcoholicThe stress of living with an alcoholic
produces dysfunctional coping behaviorproduces dysfunctional coping behavior
similar to that in post traumatic stresssimilar to that in post traumatic stress
syndrome !!syndrome !!

29. WHO ?WHO ?
EVERYONEEVERYONEEVERYONEEVERYONE
FROM “YALE TO JAIL”FROM “YALE TO JAIL”

30. QUESTION ?QUESTION ?
A.A. YOU’RE ALCOHOLICYOU’RE ALCOHOLIC
BECAUSE YOU DRINK TOOBECAUSE YOU DRINK TOO
MUCHMUCHMUCHMUCH
B.B. YOU DRINK TOO MUCHYOU DRINK TOO MUCH
BECAUSE YOU’REBECAUSE YOU’RE
ALCOHOLICALCOHOLIC

31. ANSWER !ANSWER !
B. YOU DRINK TOOB. YOU DRINK TOOB. YOU DRINK TOOB. YOU DRINK TOO
MUCH BECAUSEMUCH BECAUSE
YOU’RE ALCOHOLICYOU’RE ALCOHOLIC

32. OLD THEORYOLD THEORY
HEAVY DRINKINGHEAVY DRINKING------>>
ABUSEABUSE------>>
ALCOHOLISMALCOHOLISM

33. ALCOHOL ABUSEALCOHOL ABUSE
MEDICATE STRESSMEDICATE STRESS
MEDICATE MENTAL ILLNESSMEDICATE MENTAL ILLNESS
MOST TEENAGERSMOST TEENAGERSMOST TEENAGERSMOST TEENAGERS
MOST COLLEGE STUDENTSMOST COLLEGE STUDENTS
SOCIOPATHSSOCIOPATHS

34. NEW THEORYNEW THEORY
SOCIAL DRINKINGSOCIAL DRINKING
(NORMAL)(NORMAL)
ABUSEABUSE
(DISORDER)(DISORDER)
ALCOHOLISMALCOHOLISM
(DISEASE)(DISEASE)

35. NEW THEORYNEW THEORY
SOCIAL DRINKINGSOCIAL DRINKING
(CAN STOP)(CAN STOP)
ABUSEABUSE
(MIGHT STOP)(MIGHT STOP)
ALCOHOLISMALCOHOLISM
(CAN’T STOP)(CAN’T STOP)

36. DOUBLE MARTINIDOUBLE MARTINI
TESTTEST
HEAVY DRINKERHEAVY DRINKER
ABUSERABUSER
ALCOHOLICALCOHOLIC

37. “…the addicted brain is, in fact,“…the addicted brain is, in fact,
different in its neurobiologydifferent in its neurobiology
from the nonfrom the non--addicted brain.”addicted brain.”
Alan Leshner, Ph.D.Alan Leshner, Ph.D.
Director, NIDADirector, NIDA

38. DRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESSDRUG ADDICTION IS A COMPLEX ILLNESS
www.drugabuse.gov

39. “ …a drug hijacks one’s brain,“ …a drug hijacks one’s brain,
thereby hijacking one’s mind, andthereby hijacking one’s mind, and
then one’s life.”then one’s life.”
Alan Leshner, Ph.D.Alan Leshner, Ph.D.
Director, NIDADirector, NIDA

40. BASIC BRAIN FUNCTIONBASIC BRAIN FUNCTION
All systems in balanceAll systems in balance
Chemical messengers:Chemical messengers:
––act fastact fast
––short durationshort duration
––small amountssmall amounts

42. ALCOHOL & DRUGSALCOHOL & DRUGS
Alter the balance of the systemAlter the balance of the system
Change the messengers:Change the messengers:
––slowed downslowed down
––prolonged actionprolonged action
––decreased responsedecreased response

44. www.drugabuse.gov

46. SPECT/PET SCANSSPECT/PET SCANS
ALTERS BRAIN BLOOD FLOWALTERS BRAIN BLOOD FLOW
––INCREASEDINCREASED to areasto areas––INCREASEDINCREASED to areasto areas
required for drug userequired for drug use
–– decreaseddecreased to areas of thinking,to areas of thinking,
learning, and memorylearning, and memory

48. controlcontrol on cocaineon cocaine
www.drugabuse.gov

49. SPECT / PET ScansSPECT / PET Scans
Reduced brain glucoseReduced brain glucose
(70(70--80% of brain energy)80% of brain energy)(70(70--80% of brain energy)80% of brain energy)
Decreased brain functionDecreased brain function

51. WHY LOSS OF CONTROL ?WHY LOSS OF CONTROL ?
ALTERED BLOOD FLOWALTERED BLOOD FLOW
ALTERED MESSENGERS & EFFECTSALTERED MESSENGERS & EFFECTS
DECREASED BRAIN GLUCOSEDECREASED BRAIN GLUCOSEDECREASED BRAIN GLUCOSEDECREASED BRAIN GLUCOSE
DECREASED BRAIN DOPAMINEDECREASED BRAIN DOPAMINE
CELLULAR CHANGE OR DAMAGECELLULAR CHANGE OR DAMAGE

53. SPECT / PET ScansSPECT / PET Scans
Cellular damageCellular damage

56. SO IT’S A DISEASE !SO IT’S A DISEASE !
SO WHAT ?SO WHAT ?SO WHAT ?SO WHAT ?

57. CHRONICITYCHRONICITY
PERMANENTPERMANENT
NO RETURN TO SOCIAL DRINKINGNO RETURN TO SOCIAL DRINKING
NO RECREATIONAL DRUG USENO RECREATIONAL DRUG USE
PRONE TO RELAPSEPRONE TO RELAPSE
BUILD A DEFENSE VS. 1ST DRINKBUILD A DEFENSE VS. 1ST DRINK
RECOVERY REQUIRES MAINTENANCERECOVERY REQUIRES MAINTENANCE

58. “There exists, therefore, outside of“There exists, therefore, outside of
alkaloids and habit, a sense foralkaloids and habit, a sense for
opium, an intangible habit whichopium, an intangible habit which
lives on, despite the recasting of thelives on, despite the recasting of the
organism. The dead drug leaves aorganism. The dead drug leaves a
ghost behind. At certain hours itghost behind. At certain hours itghost behind. At certain hours itghost behind. At certain hours it
haunts the house.”haunts the house.”
JeanJean CocteauCocteau
French AuthorFrench Author
18891889--19631963

59. “ We are unable, at certain times, to“ We are unable, at certain times, to
bring into our consciousness withbring into our consciousness with
sufficient force the memory of sufferingsufficient force the memory of suffering
and humiliation of even a week or aand humiliation of even a week or a
month ago.”month ago.”
Alcoholics AnonymousAlcoholics Anonymous
AA World Services, IncAA World Services, Inc
New York,New York, 19391939

60. Childress, 1999Childress, 1999

61. MAINTAINENCEMAINTAINENCE
ALCOHOLICSALCOHOLICSALCOHOLICSALCOHOLICS
ANONYMOUSANONYMOUS

62. MAINTENANCEMAINTENANCE
ALCOHOLICS ANONYMOUSALCOHOLICS ANONYMOUSALCOHOLICS ANONYMOUSALCOHOLICS ANONYMOUS
AA is evidenced based, empirically
validated, and scientifically established
as the best form of maintenance
treatment to date!

63. PRIMARYPRIMARY
NO UNDERLYING DISEASE TO TXNO UNDERLYING DISEASE TO TX
TOTAL ABSTINENCE IS NECESSARYTOTAL ABSTINENCE IS NECESSARYTOTAL ABSTINENCE IS NECESSARYTOTAL ABSTINENCE IS NECESSARY

64. Willam Silkworth, MD:Willam Silkworth, MD:
“…the action of alcohol on these chronic“…the action of alcohol on these chronic
alcoholics is a manifestation of analcoholics is a manifestation of an
allergyallergy.” (page xxviii).” (page xxviii)
Alcoholics AnonymousAlcoholics Anonymous
AA World Services, IncAA World Services, Inc
New York,New York, 19391939

65. ALLERGYALLERGY
TO PENICILLINTO PENICILLIN
TO MILKTO MILKTO MILKTO MILK
TO ALCOHOLTO ALCOHOL
Therefore,Therefore,
TOTAL ABSTINENCETOTAL ABSTINENCE

66. PATHOLOGYPATHOLOGY
TARGET ORGAN=BRAINTARGET ORGAN=BRAIN
DEFECT=CHEMICAL IMBALANCEDEFECT=CHEMICAL IMBALANCE
THEN:THEN: AVOIDAVOID THE CHEMICALTHE CHEMICAL
AVOIDANCE=AVOIDANCE=ABSTINENCEABSTINENCE
ABSTINENCE=TOTALABSTINENCE=TOTAL

67. TOTAL ABSTINENCETOTAL ABSTINENCE
AVOID ALL LIKE DRUGS:AVOID ALL LIKE DRUGS:
BARBITURATESBARBITURATES
NONNON--BARBITURATE SEDATIVESBARBITURATE SEDATIVES
BENZODIAZEPINESBENZODIAZEPINES
––ANXIOLYTICSANXIOLYTICS
––HYPNOTICSHYPNOTICS

68. TOTAL ABSTINENCETOTAL ABSTINENCE
AVOID ALL ADDICTIVE DRUGS:AVOID ALL ADDICTIVE DRUGS:
OPIOIDSOPIOIDS
STIMULANTSSTIMULANTS
PERCEPTUAL DISTORTERSPERCEPTUAL DISTORTERS
CANNABINOIDSCANNABINOIDS
INHALANTSINHALANTS

69. TOTAL ABSTINENCETOTAL ABSTINENCE
CAUTION OTHER DRUGS:CAUTION OTHER DRUGS:
OTC DECONGESTANTSOTC DECONGESTANTS
OTC ANTIHISTAMINESOTC ANTIHISTAMINESOTC ANTIHISTAMINESOTC ANTIHISTAMINES
STEROIDSSTEROIDS
MUSCLE RELAXANTSMUSCLE RELAXANTS
“NON“NON--ADDICTIVE” ANALGESICSADDICTIVE” ANALGESICS
“NON“NON--ADDICTIVE” SEDATIVESADDICTIVE” SEDATIVES

70. PREDICTABLEPREDICTABLE
ONLY 3 OPTIONS:ONLY 3 OPTIONS:
LOCKED UPLOCKED UP
COVERED UPCOVERED UP
SOBER UPSOBER UP

71. “CATCHING”“CATCHING”
ADDICTION IS A FAMILY AFFLICTIONADDICTION IS A FAMILY AFFLICTION
THEREFORE: TX THE FAMILY AS WELL !THEREFORE: TX THE FAMILY AS WELL !

74. SPOUSE/ S OSPOUSE/ S O
COCO--DEPENDENCY TREATMENTDEPENDENCY TREATMENTCOCO--DEPENDENCY TREATMENTDEPENDENCY TREATMENT
ALAL--ANONANON

76. CHILDRENCHILDREN
FAMILY THERAPYFAMILY THERAPY
ACOA (Adult Children Of Alcoholics)ACOA (Adult Children Of Alcoholics)ACOA (Adult Children Of Alcoholics)ACOA (Adult Children Of Alcoholics)
ALAALA--TEENTEEN
ALAALA--TOTTOT

78. ACTIVITYACTIVITY------>PROBLEMS>PROBLEMS
IGNORANTIGNORANT
STUPIDSTUPID
CRAZYCRAZY
IMMORALIMMORAL
WEAKWEAK
SICKSICK

79. THEREFORE, ADDRESSTHEREFORE, ADDRESS
NOTNOT MORALLYMORALLY
BUTBUT MEDICALLYMEDICALLYBUTBUT MEDICALLYMEDICALLY
WITH:WITH:
––DIGNITYDIGNITY
––PRIVACYPRIVACY
––CONFIDENTIALITYCONFIDENTIALITY

80. REFERENCEREFERENCE
Lewis, DC: A Disease Model ofLewis, DC: A Disease Model of
Addiction. In NS Miller & MCAddiction. In NS Miller & MC
Doot (eds.)Doot (eds.) Principles ofPrinciples of
Addiction MedicineAddiction Medicine (1994).(1994).Addiction MedicineAddiction Medicine (1994).(1994).
Chevy Chase, Maryland,Chevy Chase, Maryland,
American Society of AddictionAmerican Society of Addiction
Medicine, section 1, Chapter 7,Medicine, section 1, Chapter 7,
pages 1pages 1--8.8.

82. THE “MESSAGE”THE “MESSAGE”
C D=ALCOHOLISM & ANYC D=ALCOHOLISM & ANY OTHEROTHER DDDD
C D=A DISEASE STATEC D=A DISEASE STATE
NO ONE IS IMMUNENO ONE IS IMMUNENO ONE IS IMMUNENO ONE IS IMMUNE
DENIAL=CHIEF SXDENIAL=CHIEF SX----MAJOR OBSTACLEMAJOR OBSTACLE
INTERVENTION IS NECESSARYINTERVENTION IS NECESSARY

83. THE “THE “MESSAGEMESSAGE””
TX = BIOTX = BIO--PSYCHOPSYCHO--SPIRITUALSPIRITUAL
AA/NA IS ESSENTIALAA/NA IS ESSENTIAL
MONITORING IS CRITICALMONITORING IS CRITICALMONITORING IS CRITICALMONITORING IS CRITICAL
TX WORKS W/UNALTERED RXTX WORKS W/UNALTERED RX
REHABILITATEREHABILITATE
DON’T TERMINATEDON’T TERMINATE